Background: Active surveillance (AS) of small, low-risk papillary thyroid cancers (PTCs) is increasingly being considered. There is limited understanding of why individuals with low-risk PTC may choose AS over traditional surgical management. Methods: We present a mixed-methods analysis of a prospective observational real-life decision-making study regarding the choice of thyroidectomy or AS for management of localized, low-risk PTCs <2 cm in maximum diameter (NCT03271892). Patients were provided standardized medical information and were interviewed after making their decision (which dictated disease management). We evaluated patients' levels of decision-self efficacy (confidence in medical decision-making ability) at the time information was presented and their level of decision satisfaction after finalizing their decision (using standardized questionnaires). We asked patients to explain the reason for their choice and qualitatively analyzed the results.

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Sound measured in the external canal likely represents energy lost to the environment transmitted through the middle and external ear systems, aided by the effect of both inertial and osseotympanic bone conduction. Occluding the ear leads to sound trapping and amplification. Also, the pressure exerted against the tympanic membrane reduces middle ear compliance and increases the impedance mismatch between air and the middle ear system, reflecting sound back into the external canal. This effect is further enhanced by stapes fixation to explain our data in both groups of subjects. The final common pathway in "lateralization" is probably a product of higher than normal impedance mismatch at the oval window.

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