A Narrative Review of Scars After Surgery: What to Expect

Background and Objective: For most surgical procedures, postoperative scars are inevitable. Scars that heal with poor cosmetic appearance or physical symptoms such as pain, pruritis, or tethering can have a negative impact on a patient’s quality of life. This review aims to identify current techniques for prevention of unfavorable scar formation and treatment of unfavorable scars. Methods: A narrative review of the literature was conducted using our institution’s Primo search engine to search online databases including PubMed and EBSCO, among others. Included references were selected by the first author based on relevance to the subject matter and availability in English. Key Content and Findings: Wound healing occurs as a series of complex phases: hemostasis, inflammation, proliferation, and remodeling. Deviation from the normal progression through these phases can contribute to unfavorable scar formation. Intraoperatively, meticulous tissue handling as well as suture selection can help decrease the likelihood of unfavorable scar formation. Topical silicone and pressure dressings can be used to prevent unfavorable scars as well as to treat unfavorable scars in their early stages. Laser resurfacing, dermabrasion, and intralesional corticosteroid injections can improve unfavorable scars weeks to months after they occur. Finally, surgical excision and revision is an option for unfavorable scars that do not improve with more conservative therapies. Conclusions: There are preventative measures to consider in the intraoperative and early postoperative period to help prevent the formation of unfavorable scars. Despite these efforts, unfavorable scars can still form in some patients. Understanding normal wound healing and scar formation, factors that contribute to unfavorable scar formation, and the options to revise and improve unfavorable scars can help improve patient outcomes

Evaluation of Autofluorescence Technology in the Identification of Tissue Types in Anterior Neck Surgery

Background Iatrogenic parathyroidectomy and hypocalcemia are potential risks of central neck surgery1 Resected parathyroid tissue may be reimplanted if identified quickly, mitigating risk of hypocalcemia2 Current practices of identifying and preserving parathyroids, such as frozen specimens, may incur significant costs in time and expense Autofluorescence (AF) technology takes baseline AF readings from healthy thyroid tissue and compares to other tissues in the neck There is limited data on AF profiles of all tissue types in the central neck (thyroid, thymus, benign vs. malignant lymph nodes, adipose tissue) Preliminary Outcomes (1) Investigate the impact of AF on iatrogenic hypoparathyroidism (2) Assess new AF profiles for different tissue types in the anterior neckhttps://jdc.jefferson.edu/aoa_research_symposium_posters/1001/thumbnail.jp

Molecular Diagnostics in the Evaluation of Thyroid Nodules: Current Use and Prospective Opportunities

Thyroid cancer is the most common endocrine malignancy with an estimated 43,800 new cases to be diagnosed in 2022 and representing the 7th most common cancer in women. While thyroid nodules are very common, being identified in over 60% of randomly selected adults, only 5-15% of thyroid nodules harbor thyroid malignancy. Therefore, it is incumbent upon physicians to detect and treat thyroid malignancies as is clinically appropriate and avoid unnecessary invasive procedures in patients with benign asymptomatic lesions. Over the last 15-20 years, rapid advances have been made in cytomolecular testing to aid in thyroid nodule management. Initially, indeterminate thyroid nodules, those with Bethesda III or IV cytology and approximately a 10-40% risk of malignancy, were studied to assess benignity or malignancy. More recently, next generation sequencing and micro-RNA technology platforms have refined the diagnostic capacity of thyroid nodule molecular testing and have introduced opportunities to glean prognostic information from both cytologically indeterminate and malignant thyroid nodules. Therefore, clinicians can move beyond determination of malignancy, and utilize contemporary molecular information to aid in decisions such as extent of surgery and post-therapy monitoring plans. Future opportunities include molecularly derived information about tumor behavior, neo-adjuvant treatment opportunities and response to thyroid cancer therapies

Improving Surgeon-Patient Communication in Thyroid Cancer Diagnosis and Treatment Discussions: A Narrative Review

Background and Objective: Patient experience is greatly influenced by physician-patient communication. Yet, unmet communication needs continue to be well documented in patients with thyroid cancer. This review discusses factors that may impact this communication and presents communication interventions that are currently being used with thyroid cancer patients. Methods: A narrative review of articles on the physician-patient relationship and communication in thyroid cancer published between 1985 and 2022 was conducted through PubMed and Google. An additional review of the articles referenced in the bibliography of the included articles was performed. Key Content and Findings: This review discusses communication components impacting the patientphysician relationship including physician communication skills and patient communication priorities. Additionally, modern communication interventions such as the use of pamphlets, decision aids, and multimedia platforms are reviewed. Conclusions: Developing a strong physician-patient relationship is a complex process influenced by verbal, paraverbal, and nonverbal communication. Tools such as communication training for physicians, shared decision-making approaches, and multimedia platforms have shown promise in improving communication between physicians and patients. Further study into the barriers of communication, effectiveness of adjunct tools, and patient satisfaction as it relates to communication will continue to improve outcomes

Opioid-Prescribing Practices for Post-Operative Patients in Otolaryngology: A Multiphasic Quality Improvement Project in a Single Large Institution

Objectives: In otolaryngology, postoperative pain management lacks evidence-based guidelines. We investigated opioid prescription and consumption for common procedures to develop prescribing guidelines at our institution. Study Design: Prospective, survey study. Methods: Patients who underwent surgery between July and September were given surveys upon discharge and at first follow-up visit. We assessed opioid usage and pain using the visual analog scale and opioid consumption throughout the postoperative period. Opioid prescriptions were converted to a standardized unit of 5 mg Oxycodone pills for reporting. Four procedures (transoral robotic surgery resection [TORS], sialendoscopy, parathyroidectomy/thyroidectomy, and parotidectomy) were selected for isolated analysis. Results: Of the 80 surveys that met criteria for inclusion for analysis, a total of 1,954.0 pills were prescribed, with 300.3 pills (15.4%) reported having been used by patients, leaving 1,653.7 pills (84.5%) unused. TORS (n=12) average pills used: 4.9 ± 5.9 (95% CI: 1.6-8.3); total % pills unused: 89.3%. Sialendoscopy (n=13) average pills used: 4.2 ± 5.1 (95% CI: 1.1-7.4); total % pills unused: 72.5%. Parathyroidectomy/thyroidectomy (n=22) average pills used: 3.1 ± 4.4 (95% CI: 1.7-5.5); total % pills unused: 79.2%. Parotidectomy (n=12) average pills used: 1.3 ± 2.5 (95% CI: 0.7-4.3); total % pills unused: 94.7%. Conclusions: At our institution, opioids for ((postoperative otolaryngology)) patients’ pain management in otolaryngologic procedures were prescribed in excess with 84.5% reported as unused. Procedure-specific opioid diversion pool ranged from 72.5%-94.7%. Our findings provide a foundation for procedure-specific evidence-based opioid prescription guidelines

Assessing Patient Satisfaction and Confidence After Use of Educational Video to Augment Surgical Consent for Thyroid Surgery

Introduction: Informed consent is a crucial aspect of ethical patient care, yet the increase in surgical complexity presents a challenge in achieve this properly. This study explores the use of an educational video to help standardize the consent process, increase patient retention of information, and promote patient understanding by allowing patients to replay the information remotely as often as needed. Methods: This is a perspective, survey-based study of adult patients undergoing thyroid surgery. A novel video detailing thyroid surgery containing the standard contents of informed consent was shown to patients after traditional informed consent followed by a survey on their level of comfort of the information before and after the video. Data on patient age, education level, previous surgical experience was collected. Results: Preliminary data shows that there is an increase in confidence, benefits, and knowledge of risk of the patients’ operation. We expect to find that with the addition of an educational video to the thyroid surgery consent process, patients will report a higher level of satisfaction as well as confidence in regards to their surgery. Discussion: The process of informed consent has not evolved with the complexity of procedures. The use of multimedia has been demonstrated as a valuable teaching tool in addition to traditional informed. Our study reinforces that there is a place for multimedia, specifically educational videos in informed consent for thyroid surgery as it may help patients better understand their procedure. Future aims of this study include evaluating patient comprehension with the addition of an educational video to informed consent, as well as the creation of more educational videos for head and neck surgery consent

Ultrasonographic risk stratification of indeterminate thyroid nodules; a comparison of an artificial intelligence algorithm with radiologist performance

Background, Motivation and Objective: Thyroid nodules with indeterminate or suspicious cytology are commonly encountered in clinical practice and their clinical management is controversial. Recently, genetical analysis of thyroid fine needle aspiration (FNAs) was implemented at some institutions to differentiate thyroid nodules as high and low risk based on the presence of certain oncogenes commonly associated with aggressive tumor behavior and poor patient outcomes. Our group recently detailed the performance of a machine-learning model based on ultrasonography images of thyroid nodules for the prediction of high and low risk mutations. This study evaluated the performance of a second-generation machine-learning algorithm incorporating both object detection analysis and image classification and subsequently compared performance against blinded radiologists. Statement of Contribution/Methods: This retrospective study was conducted at Thomas Jefferson University and included an evaluation of 262 thyroid nodules that underwent ultrasound imaging, ultrasound-guided FNA and next-generation sequencing (NGS) or surgical pathology after resection. An object detection and image classification model were employed to first identify the location of nodules and then to assess the malignancy. A Google cloud platform (AutoML Vision; Google LLC) was used for this purpose. Either NGS or surgical pathology was considered as reference standard upon availability. 211 nodules were used for model development and the unused 51 nodules for model testing. Diagnostic performance in 47 nodules for which pathology or NGS were available was compared to blinded reads by 3 radiologists and performance expressed as mean ± standard deviation %. Results/Discussion: The algorithm achieved positive predictive value (PPV) of 68.31% and sensitivity of 86.81% within the training model. The model was tested on images of 51 unused nodules and all 51 nodules were correctly located (100%). For risk stratification, the model demonstrated a sensitivity of 73.9%, specificity of 70.8%, positive predictive value (PPV) of 70.8%, negative predictive value (NPV) of 73.9% and overall accuracy of 66.7% in the 47 nodules. For comparison, the 3 radiologist performance in this same dataset demonstrated a sensitivity of, specificity of, PPV of, NPV of, and overall accuracy of This work demonstrates that a machine-learning algorithm using image classification performed similarly, if not slightly better than 3 experienced radiologists. Future research will focus on incorporating machine learning findings within radiologist interpretation to potentially improve diagnostic accuracy

Incorporation of a Machine Learning Algorithm With Object Detection Within the Thyroid Imaging Reporting and Data System Improves the Diagnosis of Genetic Risk.

Background: The role of next generation sequencing (NGS) for identifying high risk mutations in thyroid nodules following fine needle aspiration (FNA) biopsy continues to grow. However, ultrasound diagnosis even using the American College of Radiology\u27s Thyroid Imaging Reporting and Data System (TI-RADS) has limited ability to stratify genetic risk. The purpose of this study was to incorporate an artificial intelligence (AI) algorithm of thyroid ultrasound with object detection within the TI-RADS scoring system to improve prediction of genetic risk in these nodules. Methods: Two hundred fifty-two nodules from 249 patients that underwent ultrasound imaging and ultrasound-guided FNA with NGS with or without resection were retrospectively selected for this study. A machine learning program (Google AutoML) was employed for both automated nodule identification and risk stratification. Two hundred one nodules were used for model training and 51 reserved for testing. Three blinded radiologists scored the images of the test set nodules using TI-RADS and assigned each nodule as high or low risk based on the presence of highly suspicious imaging features on TI-RADS (very hypoechoic, taller-than-wide, extra-thyroidal extension, punctate echogenic foci). Subsequently, the TI-RADS classification was modified to incorporate AI for T4 nodules while treating T1-3 as low risk and T5 as high risk. All diagnostic predictions were compared to the presence of a high-risk mutation and pathology when available. Results: The AI algorithm correctly located all nodules in the test dataset (100% object detection). The model predicted the malignancy risk with a sensitivity of 73.9%, specificity of 70.8%, positive predictive value (PPV) of 70.8%, negative predictive value (NPV) of 73.9% and accuracy of 72.4% during the testing. The radiologists performed with a sensitivity of 52.1 ± 4.4%, specificity of 65.2 ± 6.4%, PPV of 59.1 ± 3.5%, NPV of 58.7 ± 1.8%, and accuracy of 58.8 ± 2.5% when using TI-RADS and sensitivity of 53.6 ± 17.6% (p=0.87), specificity of 83.3 ± 7.2% (p=0.06), PPV of 75.7 ± 8.5% (p=0.13), NPV of 66.0 ± 8.8% (p=0.31), and accuracy of 68.7 ± 7.4% (p=0.21) when using AI-modified TI-RADS. Conclusions: Incorporation of AI into TI-RADS improved radiologist performance and showed better malignancy risk prediction than AI alone when classifying thyroid nodules. Employing AI in existing thyroid nodule classification systems may help more accurately identifying high-risk nodules

How do parents manage irritability, challenging behavior, non-compliance and anxiety in children with Autism Spectrum Disorders? A meta-synthesis

Although there is increasing research interest in the parenting of children with ASD, at present, little is known about everyday strategies used to manage problem behaviour. We conducted a meta-synthesis to explore what strategies parents use to manage irritability, non-compliance, challenging behaviour and anxiety in their children with ASD. Approaches included: (1) accommodating the child; (2) modifying the environment; (3) providing structure, routine and occupation; (4) supervision and monitoring; (5) managing non-compliance with everyday tasks; (6) responding to problem behaviour; (7) managing distress; (8) maintaining safety and (9) analysing and planning. Results suggest complex parenting demands in children with ASD and problem behaviour. Findings will inform the development of a new measure to quantify parenting strategies relevant to ASD

Multifocal Warthin’s Tumor: An Uncommon Presentation of Bilateral Cervical Lymphadenopathy

Warthin’s tumor is the second most common benign lesion of the parotid gland. It is most commonly encountered in male smokers in the fifth to seventh decades of life. Uniquely, among benign lesions of the parotid gland, it can be seen bilaterally in 7–10% of cases. Very rarely, Warthin’s tumor can also mimic malignant or metastatic disease by presenting within cervical lymph nodes. We present a rare case of a 71-year old male smoker with bilateral parotid lesions in addition to progressively enlarging cervical and mediastinal lymphadenopathy. Excisional biopsy of a cervical lymph node ultimately revealed Warthin’s tumor