Objective To evaluate recent tracheostomy surgical experience among otolaryngology residents and general surgery residents. Study Design Retrospective database review. Setting Accreditation Council for Graduate Medical Education otolaryngology and general surgery programs. Subjects and Methods Accreditation Council for Graduate Medical Education case log data from 2005 to 2015 for resident graduates in otolaryngology and general surgery were used to obtain mean graduate tracheostomy numbers, mean graduate composite case numbers, and number of graduating residents. Market share for each specialty was estimated through the derived metric of nationwide total tracheostomy graduate experience, calculated by multiplying the number of graduating residents by the mean number of graduate tracheostomies. Linear regression analysis was used to calculate trends. Multiple linear regression analysis was used for pairwise comparison of trends. Results From 2005 to 2015, mean graduate tracheostomy numbers for otolaryngology residents declined 2.3% per year, while those for general surgery residents increased 1.8% per year. Accounting for changes in number of resident graduates, market share of tracheostomy decreased 1.0% per year for otolaryngology and increased 3.0% per year for general surgery. Mean graduate composite case numbers increased significantly by 1.8% and 1.0% per year for otolaryngology and general surgery residents, respectively. Conclusion Tracheostomy case volume in otolaryngology residency has decreased steadily in comparison with general surgery residency. However, current otolaryngology graduates have more experience in tracheostomy when compared with general surgery graduates. While otolaryngology residents have excellent exposure to tracheostomy, otolaryngology programs should be made aware of this declining trend as well as changing procedural trends, which may affect training needs.

Objective To perform a cost analysis of the routine use of intraoperative frozen section (iFS) among patients undergoing a thyroid lobectomy with "suspicious for malignancy" (SUSP) cytology in the context of the 2015 American Thyroid Association guidelines. Study Design Case series with chart review; cost minimization analysis. Setting Academic. Subjects and Methods Records were reviewed for patients with SUSP cytology who underwent thyroid surgery between 2010 and 2015 in which iFS was utilized. The diagnostic test performance of iFS and the frequency of indicated completion/total thyroidectomies based on the 2015 guidelines were calculated. A cost minimization analysis was performed comparing lobectomy, with and without iFS, and the need for completion thyroidectomy according to costs estimated from 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Results Sixty-five patients met inclusion criteria. The malignancy rate was 61.5%, 45% of which was identified intraoperatively. The specificity and positive predictive value were 100%. The negative predictive value and sensitivity were 83% and 95%, respectively. Completion/total thyroidectomy was indicated for 9% of patients; 83% of these individuals had findings on iFS that would have changed management intraoperatively. Application of the new guidelines would have resulted in a significant reduction in the frequency of conversion to a total thyroidectomy when compared with the actual management (26.1% vs 7.7%, P = .005). Performing routine iFS was the less costly scenario, resulting in a savings of $474 per case. Conclusion For patients with SUSP cytology undergoing lobectomy, routine use of iFS would result in decreased health care utilization.

4. Laryngoscope, 128:1501-1505, 2018.

MedZou Community Health Clinic is the University of Missouri’s student-run clinic (SRC) that serves the uninsured of central Missouri. While successful, MedZou has faced barriers to delivering continuity and coordination of care, spurring the creation of the Case Management Model (CMM) in 2013. This innovative model consists of medical students serving as case managers, case management directors, and MedZou clinic directors, supported by physician advisors. At its foundation, a case manager is paired with a patient who has a chronic, complex medical history along with multifactorial psychosocial issues. The case manager assesses each patient’s health needs, helps them navigate medical resources, and coordinates their medical care with the help of a physician advisor. This report describes two cases that demonstrate how the CMM has led to improvements in coordination and continuity of health care. Case 1 involves a patient with severe psoriasis who obtained mandatory lab testing before starting Humira® (adalimumab) and received Humira free of charge. Case 2 involves a patient who received timely treatment for a myocardial infarction, as well as help with Family and Medical Leave Act paperwork, medication coverage, and accessing social services post-hospitalization. In each case, the CMM led to greatly improved health outcomes and quality of life for patients and provided case managers with valuable educational experiences. We believe that this simple model can be easily implemented at other SRCs and we urge its adoption to better serve communities abroad.

Fourth branchial cleft anomalies are an exceptionally rare cause of recurrent neck mass in pediatric and adult patients. In this report, we present a case of an infected fourth branchial cleft cyst in a 20-year-old woman that presented with recurrent throat pain and deep neck abscesses. After undergoing repeated incision and drainage procedures, the patient underwent definitive management with direct laryngoscopy, ablation of the left pyriform sinus tract, left hemithyroidectomy, and excision of the branchial anomaly without evidence of recurrence. In addition to diagnosis and management, this case report highlights the unique anatomical relationship between fourth branchial anomalies and the pyriform fossa as well as the superior and recurrent laryngeal nerves.