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.

Approximately one-third of patients with differentiated thyroid cancer (DTC) have tumor recurrence within the thyroid bed, the central or lateral neck, or the mediastinum. The 2015 American Thyroid Association thyroid cancer guidelines advocate for a new risk-adapted continuum model that provides patients and clinicians with continuously updated risk stratification based on response to therapy during routine follow-up. Using serial thyroglobulin levels and ultrasound imaging, clinicians adapt treatment and follow-up algorithms specific for each patient. Although the standard treatment for most recurrent disease remains reoperative thyroid surgery, low-risk patients with low-volume persistent/recurrent disease can be followed closely with active surveillance. Most of these patients will have stable disease without progression and can avoid any reoperative surgery. Nonsurgical treatment options, including ultrasound-guided percutaneous ethanol ablation, can safely and effectively treat small foci of recurrent or persistent disease, especially in high-risk surgical patients. Reoperative thyroid surgery can be challenging because of anatomic changes after primary surgery, especially in the central neck, and is associated with high complication rates in inexperienced hands. However, with experience and appropriate preparation, rates of permanent hypoparathyroidism and injury to the recurrent laryngeal nerve can be as low as 3% and 1%, respectively. Surgeons contemplating revision thyroid surgery must possess the essential reoperative surgical skills and an intimate knowledge of regional anatomy to achieve such a low morbidity for what can often be a tedious and difficult procedure.

Objectives/Hypothesis Performance of thyroidectomy on an outpatient basis has gained popularity although many jurisdictions have not shifted their practice despite a strong safety profile. We sought to assess the uptake and safety of outpatient thyroidectomy in Ontario. Study Design Retrospective cohort study. Methods This was a population‐based retrospecive cohort of adult patients undergoing hemithyroidectomy or total thyroidectomy between 1993 and 2017 in Ontario, Canada. Outpatient surgery was defined as discharge home on the same day of surgery. Outcomes of interest include 30‐day all cause death, hematoma, emergency department use, and readmission. To adjust for confounding, propensity scores were calculated. Logistic regression models with inverse probability of treatment weighting (IPTW) were then used to estimate the exposure‐outcome relationship. Results The final cohort consisted of 81,199 patients: 8,442 underwent same day surgery and 72,757 were admitted. The proportion of patients undergoing outpatient thyroidectomy increased overtime (2.3% in 1993–1994 to 17.8% in 2016–2017). Factors associated with higher odds of outpatient thyroidectomy included: younger age, less material deprivation, less comorbidities, and higher surgeon volume. The absolute number of deaths (≤5) and hematomas (64, 0.8%) in the outpatient cohort was low. After IPTW adjustment, patients with outpatient management had lower odds of neck hematoma (OR 0.73[95CI% 0.58–0.93)], but higher odds of emergency department use (OR 1.67[95%CI 1.56–1.79]). Conclusions Outpatient thyroidectomy is not associated with an increased mortality risk. Less than one in five patients undergo outpatient thyroidectomy in Ontario, despite a well‐established safety profile. Level of Evidence 3 Laryngoscope , 131:2625–2633, 2021

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.

This Viewpoint discusses significant changes that the author has experienced in the treatment of patients with thyroid cancer throughout the last 4 decades.

Background: Papillary thyroid cancer metastasizes to the neck in ~60% of patients, necessitating lateral cervical neck dissection in cases of clinically evident metastasis.1 The nodal pattern of metastasis is to levels II, III, IV, and V, with incidences of 52%, 57%, 41%, and 21%, respectively.2 Given the rate of metastasis to level V, it is recommended to clear level V lymph nodes when performing a lateral neck dissection for metastatic papillary thyroid cancer.3 Two commonly applied approaches exist for dissection of level V depending on the volume of disease present. An anterior approach is used when there is limited disease in level V, and a posterior approach is employed with bulky or extensive disease. This video outlines the two approaches to lateral neck dissection for papillary thyroid cancer metastatic to the lateral neck. Methods: Video was created using iPhone 6 and edited in iMovie in patients undergoing right lateral neck dissection, levels II–V, for metastatic papillary thyroid cancer. An anterior approach is initially demonstrated, followed by a posterior approach in a separate patient. Written consent for video and photography was obtained for both patients. Results: Lateral neck dissection was effectively performed using both the anterior and posterior approaches to level V. Discussion and Conclusions: Clearance of level V lymph nodes is performed through either an anterior or posterior approach when performing lateral neck dissection for metastatic papillary thyroid cancer. It is recommended to employ the anterior approach when there is no clinically evident or limited metastasis in level V. The posterior approach is recommended when there is bulky or extensive disease. No competing financial interests exist. Runtime of video: 8 mins 51 secs Presented at the 2017 World Congress on Thyroid Cancer held in Boston, MA.

Importance The morbidity of bilateral lateral neck dissection (BLND) for thyroid cancers has not been described in detail. This study delineates the specific complications arising from BLND for thyroid cancers at a single high-volume center. Objective To determine the morbidity associated with BLNDs for differentiated thyroid cancers at our institution. Design, Setting, and Participants This was a retrospective review of medical records performed to identify patients having undergone BLNDs for thyroid cancers by a single surgeon at an academic, tertiary medical center in Toronto, Ontario, Canada, from 1988 to 2015. Patients who underwent BLND for papillary, follicular, or medullary thyroid cancers were identified through operative procedure codes and review of operative and pathology reports. The indication for this procedure was suspicious bilateral lateral compartment on imaging and clinical examination. Sixty-two patients who underwent BLND for thyroid cancers, with or without total thyroidectomy and central compartment dissection, were identified. Main Outcomes and Measures The main outcome measures for this study were unanticipated medical or surgical complications during the operation or in the postoperative period. Secondary measures were oncologic outcomes, including regional structural or biochemical recurrence. Results Of the 62 patients, 24 were male (39%), and 38 (61%) were female. Their mean age was 46 years (range, 17-80 years). The overall risk of permanent hypoparathyroidism was 37%. There was 1 case of unanticipated permanent recurrent nerve paralysis and 1 case of temporary nerve paresis. Postoperative chyle fistula occurred in 6 cases (10%). There were 3 readmissions within 30 days of surgery, 1 pulmonary embolism, and 1 perioperative mortality. Fifty percent of patients had pN0 contralateral necks despite preoperative clinical suspicion. Four patients were found to have anaplastic thyroid cancers intraoperatively. Five patients (8%) developed nodal recurrence in the neck. Four patients died of their disease within available follow-up (mean, 3.2 years). Conclusions and Relevance Bilateral lateral neck dissection for thyroid cancers confers a significant amount of morbidity, including a significant rate of hypoparathyroidism. Knowledge of the complications of this procedure, especially in the setting of questionable survival benefit, may assist in preoperative decision-making and patient counseling.

Background. The purpose of this study was to measure adherence rates to guideline-recommended process measures in patients with head and neck cancer.Methods. A total of 5720 patients who underwent surgery for head and neck cancer in Ontario between 1993 and 2010 were identified from administrative databases. Adherence to 4 guideline-recommended processes of care was measured and stratified by hospital and physician case volume.Results. Seventy-two percent of patients received preoperative head and neck imaging, 83% received preoperative chest imaging, 58% received preoperative multidisciplinary consultation, and 77% had appropriate follow-up visits. Higher surgeon and hospital surgical volumes were associated with higher adherence rates.Conclusion. Adherence rates to guideline-recommended processes of care in the surgical management of patients with head and neck cancer in Ontario were moderate and should be improved. Although adherence rates seem proportional to surgical volume, even the highest volume centers have room to improve. (C) 2016 Wiley Periodicals, Inc.

Background. Surgeon performed ultrasound-guided fineneedle aspirates (UG-FNAs) reduce delay in diagnosis and allow for surgeon surveillance. We present the first report on a learning curve and impact of head and neck surgical trainees on adequacy rates.Methods. Thyroid UG-FNA biopsies from 2009 to 2013 were reviewed retrospectively. Specimen adequacy, cytologic diagnosis, and surgical pathology were used to calculate adequacy and accuracy.Results. One thousand sixty-seven biopsies were examined in 723 individuals. The adequacy rate from adoption into practice improved from 71% to 78% to 85% over 300 cases. When UG-FNA was subsequently taught to trainees, adequacy rates varied among trainees p < .037), and there were higher nondiagnostic rates earlier in training (p = .04). Adequacy was not related to size or palpability, but cystic lesions yielded more inadequate specimens (p < .001).Conclusion. Surgeon performed UG-FNA biopsy can be performed adequately in an outpatient setting. Adequacy rates reach acceptable levels after 300 cases, whereas trainee involvement impacts adequacy rates. (C) 2015 Wiley Periodicals, Inc.

Background. The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) is used in surgical decision-making according to malignancy risk in each category. Malignancy risk in atypia/follicular lesion of undetermined significance (AUS/FLUS) is estimated in BSRTC to be 5% to 15%, but institutional data have varied widely.Methods. We conducted a post-BSRTC 4-year retrospective analysis of index thyroid nodule cytology and histopathology in an academic head and neck endocrine surgery setting.Results. Of 2939 thyroid cytology reports from 1944 patients, the most advanced BSRTC category was AUS/FLUS in 233 patients (12.0%) of which 187 went to thyroidectomy. In AUS/FLUS, the upper and lower boundary estimates of the malignancy rate were 46% and 37%, accord-ingly. The malignancy rate did not vary significantly by cytopathologist or cytopathologic features.Conclusion. Malignancy rates in AUS/FLUS vary by institution from 6% to 46%. Given the subjective nature of thyroid cytopathology and interpretation of the BSRTC categories, guidelines should encourage the use of institution-specific data on malignancy risk in treatment decisions. (C) 2015 Wiley Periodicals, Inc.

The pupose of this study was to describe variations in incidence and resection rates of patients with oral cavity squamous cell carcinoma (SCC) in Ontario.

ABSTRACTBackgroundThe purpose of this study was to compare outcomes between human papillomavirus (HPV)‐related versus ‐unrelated head and neck cancer after pathological positive planned neck dissection.MethodsPositive planned neck dissection for head and neck cancers from 1998 to 2010 were included in this study. Outcomes after planned neck dissection were compared between HPV‐related versus ‐unrelated cohorts. Multivariate analysis identified survival predictors.ResultsHPV‐related head and neck cancer (n = 32) had better 5‐year overall survival (48% vs 27%; p = .021), marginally lower second malignancy (7% vs 16%; p = .13), but similar local, regional, and distant control (87% vs 89%; 94% vs 89%; 62% vs 58%, respectively) versus HPV unrelated (n = 38). HPV status conferred reduced risk of death (hazard ratio [HR], 0.5; p = .038) after adjusting for age, smoking, and initial T and N classifications.ConclusionThis study reveals that positive planned neck dissection for HPV‐related head and neck cancer represents a biologic unfavorable subset of the HPV population with unsatisfactory survival attributable to distant metastasis. The longer survival compared to the HPV‐unrelated counterpart is likely related to a marginally lower second malignancy rather than better disease control. © 2014 Wiley Periodicals, Inc. Head Neck 37: 946–952, 2015

Because of the relative rarity of head and neck malignancies and their complex treatment, some groups have advocated for regionalized care. Studies comparing high‐ and low‐volume centers have demonstrated mixed results.

Background Incidental thyroid nodules are commonly found by radiological studies done for other indications. The yearly incidence of thyroid cancer is increasing, in part because of detection of nonpalpable nodules on imaging performed for unrelated issues. Methods All new patients referred to a high‐volume thyroid surgeon for thyroid nodules were reviewed between February 2009 and January 2011. Data regarding patient demographics, risk factors, referring physician, radiologic findings, fine‐needle aspiration (FNA) results, and management were reviewed. Results One hundred thirty‐three of 729 patients (18.2%) had a thyroid nodule or nodules incidentally found on ultrasound, MRI, CT, nuclear imaging, or chest x‐ray. Fifty‐five patients (41.4%) were managed surgically, with 35 (63.6%) of those having thyroid cancer on final surgical pathology. Conclusion Based on radiologic findings, risk factors, and FNA results, many incidental thyroid nodules can be observed. Incidental thyroid nodules should be evaluated in the same fashion as a palpable thyroid nodule. © 2013 Wiley Periodicals, Inc. Head Neck 36 : 126–129, 2014

Background The purpose of this study was to discuss the appropriate management options for parathyroid carcinomas, which is still a subject of controversy. Methods A retrospective chart review of 16 patients with parathyroid carcinoma was undertaken to determine the clinical outcome. Results All patients were initially treated with surgery, and 11 patients received adjuvant radiotherapy. The 5- and 10-year disease-specific survival rates were 100% and 80%, respectively; the 5- and 10-year disease-free survival rates were 69% and 43%, respectively. The 5- and 10-year locoregional control rates were 69% and 52%, respectively; the 5- and 10-year distant control rates were 89% and 74%, respectively. In this cohort, none of the clinicopathologic parameters could be defined as a predictor. Conclusion In patients with parathyroid carcinoma, definition of prognostic factors and the role of adjuvant radiation treatment has still to be elucidated. Nevertheless, angioinvasion and positive resection margins are critical factors regarding disease-free survival in patients with parathyroid carcinomas. (c) 2012 Wiley Periodicals, Inc. Head Neck, 2013

Background The purpose of this study was to determine whether the proportion of metastatic cervical lymph nodes resected (metastatic lymph node ratio [MLNR]) predicted papillary thyroid carcinoma (PTC) recurrence, and whether MLNR could alter the predictive ability of TNM nodal classification for recurrence in PTC. Methods We conducted a retrospective review of patients with PTC who underwent a total or near-total thyroidectomy with at least 1 lymph node removed at our institution. Results Of 253 patients, 35 (13.8%) developed recurrent disease. The total MLNR (ratio between total metastatic lymph nodes and total number of lymph nodes resected) independently predicted PTC recurrence (odds ratio [OR], 1.024; 95% confidence interval [CI], 1.0101.039; p = .001). In receiver operating characteristic (ROC) curve analysis, TNM nodal classification with total MLNR had greater accuracy in predicting PTC recurrence than did TNM nodal classification alone (0.726 and 0.675, respectively). Conclusion MLNR is an independent predictor of PTC recurrence and enhances the predictive value of TNM nodal classification. (c) 2012 Wiley Periodicals, Inc. Head Neck, 2013

To the Editor: Vaisman and colleagues recently suggested to rule out I ablation in patients with low-risk differentiated thyroid carcinoma (DTC) having negative neck ultrasound, negative thyroglobulin (Tg) antibodies (TgAb), and serum rhTSH-stimulated Tg levels from <1 to 5 ng/mL, measured 3 months after thyroidectomy and selective central compartment neck dissection. In our opinion, however, some critical points concerning Tg measurement need to be further elucidated. In fact, even if measurement of serum Tg levels at the time of I remnant ablation proved to be useful to predict early and long-term outcome of patients, discrepancies between undetectable Tg levels and residual I uptake on a posttreatment whole body scan (PT-WBS) have been reported. In particular, recurrences and metastases on the I PT-WBS scan were proved in 6.3% to 8.5% of patients with an undetectable preablative Tg value. Serum Tg levels that are measured by different methods vary by as much as a factor of 4, even after methods calibration against CRM 457 reference material. Another major problem that hampers accurate Tg measurement is the interference in the Tg assay by TgAb and heterophile antibodies (HAb), resulting in either an underestimation or overestimation of the serum Tg concentration. Immunometric Tg assays may also be subject to a high-dose hook effect, leading to inappropriately normal or low serum Tg values in sera with very high Tg concentrations, which require dilution for accurate measurement. Finally, undetectable serum Tg became detectable in a significant percentage of DTC patients by changing assays, suggesting that in many patients a decrease in immunological reactivity or structural changes of the Tg molecule caused the undetectable Tg levels. Recently, we proved that problems of various kinds may occur with Tg measurement at the time of ablation in up to 1 in 6 patients. Despite extensive laboratory work-up (ie, retesting using different Tg and TgAb immunoassays, recovery test, HAb screening) Tg still was undetectable in about 1 of 5 patients in our series. Considering the sensitivity of both serum Tg and I, an undetectable Tg in the presence of any residual I uptake is highly suspicious for having to deal with pitfalls in Tg measurement. Consequently, the non-negligible risk of a positive PT-WBS in patients with an undetectable Tg level should be considered if Tg is used as a yardstick to rule out I ablation in DTC patients. A single rhTSH-aided I administration (1.1–3.7 GBq) effectively ablates thyroid remnants in most DTC patients, without relevant shortand long-term side effects. The highly sensitive PT-WBS proved to be useful in prognostic stratification of DTC patients and validation of serum Tg as a tumor marker in the long-term DTC follow-up. Additionally, the need for further rhTSH stimulations is becoming virtually absent in low-risk patients treated by thyroid ablation if a second-generation Tg assay is used. Based on these considerations, the reason to perform an rhTSH stimulation every year in 90.4% of low-risk DTC patients to avoid I ablation, as proposed by Vaisman and colleagues, remains at least debatable in our opinion.

Background Our aim was to report patterns of failure and histopathological predictors in patients with head and neck cancer treated by planned neck dissection. Methods We reviewed all new patients with head and neck cancer who underwent a planned neck dissection in our institution from 1998 to 2007. Patterns of failure after positive planned neck dissection were reported. The frequency and predictive value of histopathologic features were analyzed. Results Fifty positive planned neck dissection and 144 negative planned neck dissection cases were identified. The positive planned neck dissection cohort had lower 5-year overall survival (OS; 33% vs 77%; p < .01), a significantly higher distant metastasis (DM; 44% vs 11%; p < .01), a moderately lower local (86% vs 96%; p < .01), and a similar regional control (94% vs 99%; p = .07) compared to the negative planned neck dissection cohort. Extracapsular extension/carcinoma within soft tissue and lymphovascular invasion were adverse survival predictors for patients with positive planned neck dissection on univariate and multivariate analysis. Conclusion Positive planned neck dissection is associated with lower survival, predominantly attributed to significantly increased DM rather than reduced locoregional control. (c) 2011 Wiley Periodicals, Inc. Head Neck, 2012

Background. Follicular carcinomas have been reported as 10% to 15% of thyroid malignancies. Refinements in the histologic criteria applied in the classification of follicular lesions have occurred. We aim to document the true incidence of follicular cancers in a cohort from a high-volume endocrine practice.Methods. Patient charts were reviewed and cancers were classified into major subtypes; papillary cancers were further classified by common variants. Proportions were compared to historic Surveillance, Epidemiology, and EndResults (SEER) database proportions. Results. Only 2.7% of patients had follicular carcinoma. The proportion of patients with follicular cancer was less than the reported rates of 10% to 15%, and less than the 6.7% extrapolated from SEER.Conclusion. The proportion of follicular cancers is less than traditionally reported. This change is due to an increased incidence of papillary cancers, and modifications of the histologic criteria used for classification of encapsulated follicular lesions. There are potential prognostic consequences, as follicular cancers have been perceived as more aggressive. (C) 2010 Wiley Periodicals, Inc. Head Neck 32: 1629-1634, 2010

Background. Though age and primary tumor size predict cancer-specific survival in well-differentiated thyroid carcinoma (WDTC), their influence on residual/recurrent disease has not been elucidated.Methods. In a retrospective study, residual/recurrent disease was defined by the surrogate outcome of positive (>= 2 mu g/L) follow-up stimulated thyroglobulin after surgery and radioactive remnant ablation. Age, primary tumor size, and clinical staging systems were examined in the context of stimulated thyroglobulin outcome.Results. A total of 246 patients were followed up for a mean of 5.8 years. No significant difference in age (t(239) = 0.61, p > .05) or tumor size (t(237) = 0.16, p > .05) was found among patients with positive follow-up stimulated thyroglobulin compared with those with negative results. pTNM staging failed to demonstrate significant, stage-dependent increase in the percentage of patients with positive stimulated thyroglobulin, chi(2) (2, N = 229) = 0.17, p > .05, unlike staging based solely on surgical pathology, chi(2) (2, N = 241) = 34.97, p < .001.Conclusion. Age, primary tumor size, and pTNM staging do not predict risk for residual/recurrent WDTC, whereas extra-thyroidal extension at initial surgery is predictive. (c) 2009 Wiley Periodicals, Inc. Head Neck 31: 782-788, 2009