Salivary Gland Tumors: A 20 Year Review From a Single Community Practice.

Objective: Salivary gland tumors are a heterogenous group of lesions with variable pathology and clinical outcomes. Most published data are derived from studies conducted at tertiary care centers. Our study analyzed the experience from a community setting to determine significant differences, if any, in pathological distribution and clinical outcomes compared to the existing literature. Methods: We performed a retrospective analysis of all major salivary gland tumors that presented to a large community practice over a 20 year period. Retrospective chart analysis was performed for demographics, clinical presentation, imaging, cytology, histopathology, and clinical outcome data. Results: Of 806 patients, the parotid gland was the most common site in 683 patients (84.7%), followed by submandibular in 78 (9.7%) and sublingual in 45 (5.6%). A total of 203 patients were managed conservatively with observation without definitive diagnosis or lost to follow-up. A total of 495 patients underwent surgical intervention within the community practice. Twenty-six patients underwent surgical excision at an outside hospital. Eighty-two patients were determined to have a benign diagnosis based on ultrasound-guided fine needle aspiration or excisional biopsy alone. Final histopathology was benign in 505 cases (83.7%), while 98 tumors (16.3%) received a diagnosis of primary or secondary malignancy. For the parotid gland, pleomorphic adenoma (155) and Warthin's tumor (155) were the most common benign diagnoses, while mucoepidermoid carcinoma (13), adenocarcinoma (8), and acinic cell carcinoma (8) were the most common primary malignancies. Conclusions: We found a higher rate of benign tumor pathology compared to the existing literature. While the outcome data on surgical treatment of benign tumors are comparable to the existing literature, the same conclusion cannot be drawn for malignant tumors, given relatively small numbers in our series and likely disparity in the complexity of the surgical cases in tertiary care centers.

Point-of-care ultrasound scan as the primary modality for evaluating parotid tumors.

Objectives: This study aimed to explore ultrasonography as a single imaging modality for the initial assessment of parotid lesions compared to computed tomography (CT) and magnetic resonance imaging (MRI). Methods: A retrospective cross-sectional study was performed on 264 parotid gland lesions evaluated in a dedicated point-of-care ultrasound (POCUS) clinic with concurrent fine needle biopsy (FNB). Two hundred and nine of these lesions also underwent CT or MRI imaging. Histopathology results, when available, were recorded and compared to imaging impressions. Results: Surgeon-performed POCUS classified parotid masses accurately when compared to final histopathology (90/96, 94%). Using predefined criteria, POCUS determined the nature of parotid lesions more definitively than the descriptive CT or MRI radiology reports (p <.001). Sub-analysis showed that ultrasonography was able to distinguish between benign pathologies with high degree of accuracy (Warthin tumor-82%, pleomorphic adenoma-64%). Conclusions: POCUS can accurately distinguish between benign and malignant parotid lesions. POCUS may suffice as the only imaging study for benign lesions, obviating the need for additional cross-sectional imaging. This can be combined with fine needle or core biopsy in the same visit, resulting in expedient diagnosis, low cost, and lack of radiation exposure. Level of Evidence: 2b, individual cross-sectional cohort study.

Milan system for reporting salivary gland cytopathology: Adoption and outcomes in a community setting.

BACKGROUND: Milan system for reporting salivary gland cytopathology (MSRSGC) was introduced to standardize reporting of salivary gland cytopathology. METHODS: A retrospective review of ultrasound-guided fine needle biopsy of salivary gland lesions was performed between January 2018 and May 2021 at a community otolaryngology practice. Diagnostic accuracy and rate of diagnostic sialoadenectomy were calculated. RESULTS: A total of 203 FNAs (fine needle aspiration) were performed in 184 patients. MSRSGC was utilized in 87/203 cytopathology reports, with a diagnostic accuracy of 84%. Descriptive reporting was used in 115 FNAs, with a diagnostic accuracy of 89% (p = 0.68). Sialoadenectomy rate was 41% for MSRSGC compared to 36% in descriptive cytopathology (p = 0.48). CONCLUSIONS: MSRSGC is as accurate as descriptive cytopathology and the rate of diagnostic sialoadenectomy between both groups is similar in our community. The MSRSGC brings uniformity and standardization to the FNA reporting process.

Long-term Follow-up of Cytologically Indeterminate Thyroid Nodules Found Benign on Molecular Testing: A Validation Study.

Objective: Molecular testing has revolutionized management of indeterminate thyroid nodules (Bethesda categories III and IV). Few studies have attempted to validate the negative predictive value of molecular tests. Using long-term observation as a surrogate for surgical resection, we sought to examine the false-negative rate of "benign" indeterminate thyroid nodules on molecular testing. Study Design: Case series with retrospective data collection and chart review. Setting: Large community-based practice with multiple satellite offices. Methods: All patients with thyroid nodules that underwent ultrasound-guided fine-needle aspiration biopsy between 2013 and 2019 were evaluated through retrospective analysis. Cytologically indeterminate nodules reflexively underwent molecular testing to guide clinical management. Observation was recommended for lesions with benign molecular testing, and these nodules were followed clinically and by ultrasound. Results: A total of 2011 nodules underwent fine-needle aspiration, of which 280 (14%) were indeterminate thyroid nodules. Of those 280 nodules, 100 (36%) were benign on molecular testing. Three samples were excluded from analysis due to patient deaths from unrelated causes. Surgical resection was recommended in 16 of the 97 nodules (17%), with the majority due to size and compressive symptoms. Histopathology was available in 14 nodules that underwent surgery, with 1 demonstrating minimally invasive follicular carcinoma. Conclusion: While molecular testing is safe to use in guiding management of indeterminate thyroid nodules, consideration of individualized clinical factors and close long-term follow-up remains paramount.

Comparative Study of ACR TI-RADS and ATA 2015 for Ultrasound Risk Stratification of Thyroid Nodules.

OBJECTIVE: To study the adoption rate of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) scoring system over a 3-year period in a community setting and compare its performance with that of the American Thyroid Association 2015 (ATA 2015) ultrasound risk scoring system. STUDY DESIGN: Case series with prospective data collection and retrospective chart review. SETTING: Large community-based practice with multiple satellite offices and a dedicated thyroid ultrasound clinic. METHODS: All patients referred to the thyroid clinic between January 2018 and December 2020 for ultrasound-guided fine-needle biopsy were assigned an ATA 2015 risk score in a prospective manner immediately prior to biopsy. ACR TI-RADS scores were recorded through retrospective chart review of the radiologist report. Performance of the 2 systems was compared with cytology as the gold standard. RESULTS: A total of 949 nodules underwent biopsy, of which 236 had available data for both scoring systems. There was a 33.8% increase in adoption of the ACR TI-RADS over the 3-year study period. The ATA 2015 guidelines yielded sensitivity and specificity of 81.6% and 54.5%, respectively, as opposed to 73.7% and 27.0% for the ACR TI-RADS. CONCLUSION: In our community, there has been a gradual increase in adoption of the ACR TI-RADS, although the ATA 2015 risk scoring system has performed better.

A Blinded Randomized Trial Comparing 2 Needle Gauges for Fine-Needle Biopsy of Thyroid Nodules.

OBJECTIVE: To compare diagnostic capability and patient pain between 25-gauge (25G) and 27G needles for ultrasound-guided fine-needle biopsy of thyroid nodules. STUDY DESIGN: Prospective blinded randomized trial. SETTING: Thyroid clinic in otolaryngology practice in a community. METHODS: A prospective randomized blinded trial was conducted on 148 thyroid nodules in 107 patients undergoing ultrasound-guided fine-needle biopsy. Needle gauge was randomized to individual nodule. Patients were blinded to the needle size used. All specimens were assessed via the Bethesda System for Reporting Thyroid Cytopathology and assigned a morphologic quantitative score based on number of thyroid cells and lymphocytes, amount of colloid, and degree of blood/fibrin artifact in each sample. Patient pain experience was scored. A chi-square test was used to compare nondiagnostic rates, and differences in cytologic morphology and pain scores were compared with 2-sample Student t tests. RESULTS: Of the 148 nodules, 77 were biopsied with 25G needles and 71 with 27G needles. Twenty-five percent (19/77) of the samples obtained with 25G needles yielded a nondiagnostic cytology result (Bethesda category 1) as compared with 11% (8/70) in the 27G group (P = .0282; 95% CI, 1.47%-25.97%). On average, samples from 25G needles had a higher blood/fibrin quantitative score (P = .043; 95% CI, -0.64 to -0.010). There were no differences in pain between groups. CONCLUSION: Use of a 27G needle for fine-needle biopsies is not only safe and feasible but desirable and highly recommended, as it yields better diagnostic information.

Total Thyroidectomy as an Ambulatory Procedure in Community Practice.

OBJECTIVE: Increasingly, total thyroidectomy is offered as an ambulatory procedure. Most of the relevant outcomes research derives from academic centers, but most thyroid surgeries are performed in the community. The goal of this study is to evaluate the safety of total thyroidectomy performed as an ambulatory procedure in a community otolaryngology practice. STUDY DESIGN: Retrospective review and national database analysis. SETTING: A single community otolaryngology practice. METHODS: Adult patients undergoing total thyroidectomy by a single otolaryngologist between 2013 and 2019 were divided into 2 cohorts: planned ambulatory and planned admission. Charts were reviewed for demographics and surgical outcomes in the 2 groups. The Healthcare Cost and Utilization Project databases for New York and Florida between 2015 and 2016 were also analyzed to compare outcomes of thyroidectomy as an ambulatory surgery between different practice settings. RESULTS: A total of 99 total thyroidectomies were performed during the study time period; 66 of 99 (67%) were planned as ambulatory procedures and 33 of 99 (33%) were planned admissions. Five of the 66 (8%) planned outpatient surgeries required admission. Complications of vocal fold dysfunction, symptomatic hypocalcemia, and seroma formation were more commonly seen in the inpatient cohort. Only 2 ambulatory patients required admission after discharge. Nationally, odds of complication were higher for ambulatory total thyroidectomy at nonteaching practice sites, which is not duplicated in our study. CONCLUSIONS: Ambulatory total thyroidectomy can be undertaken safely in the community in carefully selected cases.

Diagnostic Accuracy of Fine-Needle Biopsy for Salivary Gland Neoplasms in a Community Otolaryngology Practice.

OBJECTIVE: To assess the diagnostic accuracy of fine-needle biopsy (FNB) of salivary gland neoplasms via ultrasound (US) or palpation guidance by an otolaryngologist in a community practice. STUDY DESIGN: Retrospective chart review. SETTING: Community otolaryngology practice. METHODS: Retrospective analysis was conducted for all office-based salivary gland FNBs from a community practice from 2005 through 2018. There were 433 FNBs performed among 370 patients. The likelihood of achieving a diagnostic result based on method (US vs palpation guidance) was calculated. Of this cohort, 196 cases had surgical follow-up (parotid gland, n = 168; submandibular gland, n = 28). Correlation of preoperative FNB results to final surgical pathology was performed and measures of diagnostic accuracy computed. RESULTS: US-guided FNBs were more likely to achieve a diagnostic result than FNBs obtained via palpation guidance (P = .00002). Parotid gland FNBs demonstrated a sensitivity and specificity of 78.57% and 92.44%, respectively. Submandibular FNBs demonstrated a sensitivity and specificity of 57.14% and 93.74%. CONCLUSION: FNBs performed under US guidance are more likely to achieve a diagnostic specimen than those performed under palpation guidance. FNBs of parotid gland tumors may be assessed with diagnostic accuracy in the community setting that is similar to that achieved at tertiary care centers. Further research is needed to ascertain whether this finding extends to FNBs of submandibular gland tumors. Offering this procedure at point of care in the community may improve compliance and reduce wait time.

Ultrasound-Guided Fine-Needle Biopsy of First 1000 Consecutive Thyroid Nodules: Single-Surgeon Experience.

OBJECTIVE: To study the feasibility, safety, and learning curve of ultrasound-guided fine-needle biopsy (USGFNB) performed by a newly trained otolaryngologist in a community office in a setting. STUDY DESIGN: Collect USGFNB data of all thyroid nodules in a prospective manner. SETTING: A dedicated ultrasound clinic in a large community-based practice, operated by a single surgeon with the purpose of providing office-based point-of-care diagnostic ultrasonography and USGFNB. SUBJECTS AND METHODS: Data on the first 1000 unselected consecutive thyroid nodules that underwent USGFNB over a 3-year period were analyzed. Chi-square analysis was used to assess the statistical significance of characteristics of diagnostic vs nondiagnostic nodules. A multivariate regression analysis was conducted to determine nodule characteristics predictive of adequate sampling. Diagnostic yield and time efficiency data were plotted over a 3-year period to study the learning curve for the USGFNB procedure performed by an operator with no previous experience. RESULTS: A total of 1000 nodules in 734 patients including 142 males and 592 females (age range, 17-87 years) were studied. Of the patients, 188 of 734 had more than 1 nodule biopsied, with a maximum of 4 nodules biopsied in 1 setting. The procedure was successfully completed in all patients, with no major complications. A steep learning curve was observed, and adequate samples were obtained in 91.9% of the patients on the first attempt. The cystic nature of the nodule was the biggest predictor of a nondiagnostic yield. CONCLUSIONS: Otolaryngologist-performed USGFNB of the thyroid is safe, effective, and desirable.

Office-Based Ultrasound-Guided FNA with Molecular Testing for Thyroid Nodules.

OBJECTIVE: Ultrasound-guided fine-needle aspiration (FNA) biopsy is the primary method of evaluating thyroid nodules. Up to one-third of FNA results are reported to be of "indeterminate" cytology, which carries a 25% malignancy risk. Most of these patients are referred for diagnostic surgery, which results in many unnecessary interventions. We implemented an FNA protocol combining expert thyroid cytopathology and molecular testing of indeterminate lesion in our community practice. This study is a report of the outcomes from this protocol as compared with historical data in the same setting over a similar period. STUDY DESIGN: Case series with planned data collections and retrospective chart reviews. SETTING: A large community-based practice with multiple satellite offices. SUBJECTS AND METHODS: A total of 264 thyroid nodules (196 patients) were evaluated under the new protocol from January to December 2014, and data were collected in a prospective manner. Historical data for a similar period (2012), obtained by chart review, included 164 nodules (134 patients) biopsied in a hospital setting by a number of radiologists, with cytologic interpretations completed by community-based pathologists. Statistical analyses included χ(2) and Fischer's exact tests. RESULTS: Based on the new protocol, the rate of indeterminate lesion diagnosis was reduced from 24% to 10% (P = .006) and the rate of diagnostic surgery from 24% to 6% (P < .001). Of the patients who underwent diagnostic surgery, 58% had evidence of malignancy, as compared with 12% in our previous experience (P = .04). CONCLUSION: Expert cytopathologic analysis combined with molecular testing of indeterminate FNA samples significantly reduced unnecessary operations.

BRAF and Epithelial-Mesenchymal Transition: Lessons From Papillary Thyroid Carcinoma and Primary Cutaneous Melanoma.

The increased prevalence of BRAF mutations in thyroid carcinoma and primary cutaneous melanoma (PCM) hint that dysregulation of BRAF might contribute to the noted association between PCM and thyroid carcinoma. A recent study evaluating the rate of BRAFV600E mutations among patients who had been diagnosed with primary papillary thyroid carcinoma (PTC) and PCM showed that patients with either PCM or PTC were at an increased risk of developing the other as a second primary malignant neoplasm. Furthermore, the authors noted that samples from patients suffering from both malignancies exhibited a higher rate of incidence of the BRAFV600E mutation, compared with patients not suffering from both malignancies. These studies support the hypothesis that the pathogenesis of these 2 malignancies might share a conserved molecular pattern associated with dysregulation of the BRAF protein. One mechanism through which BRAF might contribute to PCM and thyroid carcinoma progression is through induction of epithelial-mesenchymal transition (EMT). Specifically, the Snail/E-cadherin axis has been demonstrated as a pathway dysregulated by BRAF, leading to EMT in both malignancies. Our analysis focuses on the results of these recent investigations, and through a review of select molecules relevant to EMT, looks to provide a context by which to better understand the relevance and role of stromal-parenchymal signaling and the BRAF mutation in the pathogenesis of PTC and PCM.

Paranasal sinus development: a radiographic study.

OBJECTIVE: To demonstrate the development of the paranasal sinuses in a pediatric population by computed tomography scans. STUDY DESIGN: Radiology records at a tertiary care institution were reviewed for the computed tomography scans of the face, orbit, or paranasal sinuses in patients aged 0 to 12 years. METHODS: Computed tomography scans were reviewed by a head and neck radiologist and otolaryngologist for the development of the frontal, maxillary, ethmoid, and sphenoid sinuses. The size of the pneumatized paranasal sinuses was measured in two planes and graded on a scale of 0 to 3. Ossification of the maxillary crest and vomer, obliteration of the foramen cecum, and development of agger nasi cells, Haller cells, and the superior turbinate were studied. Patients with syndromes, nasal stenosis, choanal atresia, or cystic fibrosis were excluded from the study. RESULTS: In all, 91 computed tomography scans in 66 patients were studied. Serial development could be followed in 16 patients who underwent repeat scans. Patients were divided into six age cohorts based on their age at the time of the scan: 0 to 3 months (10%), 3 to 12 months (13%), 1 to 3 years (13%), 3 to 5 years (20%), 5 to 8 years (29%), and 8 to 12 years (16%). Ethmoid sinuses were the first to fully develop, followed sequentially by maxillary, sphenoid, and frontal sinuses. Each sinus has a rapid rate of development during specified age cohorts. CONCLUSION: The results will aid the physician when correlating the clinical and radiographic findings of pediatric patients aged 0 to 12 years who are being evaluated for sinus disease and potential surgical intervention.

Hereditary hemorrhagic telangiectasia: a review of 76 cases.

OBJECTIVES/HYPOTHESIS: Hereditary hemorrhagic telangiectasia has long been viewed as a rare condition. Recent evidence indicates that the disorder is more frequent than previously thought. Recalcitrant epistaxis is a salient feature of this disease, and the otolaryngologist is often called on to make the diagnosis and guide the primary management of patients with hereditary hemorrhagic telangiectasia. Wider recognition of this condition, awareness of the natural history and associated findings, appropriate workup and screening for arteriovenous malformations (lungs, brain, liver), and knowledge of appropriate interventions can help avoid the considerable morbidity associated with hereditary hemorrhagic telangiectasia. STUDY DESIGN: Retrospective review. METHODS: Records of patients treated by the senior author (S.M.S.) for hereditary hemorrhagic teleangiectasia from 1993 to 2000 were reviewed. RESULTS: Seventy-six patients were identified, 98% of whom had epistaxis as their presenting complaint, with 75% having a family history of hereditary hemorrhagic telangiectasia. The severity of epistaxis varied in the patients: 66% had mild, 21% moderate, and 13% severe epistaxis. Sixty-four percent of patients had no transfusions, 25% had 1 to 10 transfusions, and 11% of patients had more than 10 transfusions. Complications of hereditary hemorrhagic telangiectasia were documented in 30% of patients. Screening for arteriovenous malformations was performed in only 34% of patients. Eighty-two percent of patients received a variable number of Nd:YAG laser treatments. CONCLUSIONS: The study presents the largest retrospective review of patients treated for hereditary hemorrhagic telangiectasia by a single otolaryngologist. The importance of a multidisciplinary approach facilitated by the otolaryngologist for evaluation of concomitant complications and morbidity (arteriovenous malformations) from hereditary hemorrhagic telangiectasia is demonstrated. An algorithm for controlling the epistaxis is presented.