Publications by authors named "Jagdish Dhingra"

13 Publications

  • Page 1 of 1

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

OTO Open 2021 Apr-Jun;5(2):2473974X211013732. Epub 2021 May 10.

Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA.

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 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 ( = .0282; 95% CI, 1.47%-25.97%). On average, samples from 25G needles had a higher blood/fibrin quantitative score ( = .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.
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May 2021

Lateral approach improves surgical access to the superior pole in giant endemic goiters.

Gland Surg 2021 Mar;10(3):973-979

Department of Otolaryngology Head and Neck Surgery, Tufts University Medical Center, Boston, Massachusetts, USA.

Background: Surgical management of mega-goiters in endemic areas with extreme iodine deficiency presents unique challenges. Based on our initial 5-year experience (2007 to 2011) operating on mega-goiters in Gitwe, Rwanda, Africa, we modified our technique to a lateral approach which affords better exposure of the superior pole vessels and other vital neurovascular structures, thereby improving safety. We describe this lateral approach technique and review outcomes compared to the standard technique.

Methods: From 2007 to 2019, we have conducted 13 annual surgical missions to low resource setting in Gitwe, Rwanda. Retrospective chart review of surgeries between 2012 and 2019 was performed to study outcomes using standard approach and lateral technique during the same time period.

Results: Over a period of 8 years (2012 to 2019), out of 192 total cases, lateral approach was used in 35 patients. No patient experienced significant intra-operative blood loss requiring transfusion. One patient had a post-operative hematoma requiring surgical intervention. Vocal cord mobility testing by transcutaneous laryngeal ultrasound was implemented in 2016. Of all patients, incidence of vocal cord weakness was 8.0% (11/137 patients tested) with less than 1/3 of these symptomatic. There was no statistically significant difference in vocal cord weakness noted in the two approaches (3/23 in lateral approach and 8/114 in standard approach) by Fisher's exact test (P=0.34).

Conclusions: Lateral approach, by affording optimal exposure of the great vessels and the laryngeal nerves, reduces the risk of bleeding and nerve injury. Furthermore, inferiorly based strap muscle flap provides excellent coverage and cosmetic outcome.
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March 2021

Total Thyroidectomy as an Ambulatory Procedure in Community Practice.

OTO Open 2020 Jul-Sep;4(3):2473974X20957324. Epub 2020 Sep 29.

Tufts Medical Center, Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA.

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.
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September 2020

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

OTO Open 2020 Jul-Sep;4(3):2473974X20949184. Epub 2020 Aug 27.

Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA.

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 ( = .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.
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August 2020

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

OTO Open 2020 Apr-Jun;4(2):2473974X20929008. Epub 2020 Jun 2.

Department of Otolaryngology-Head and Neck Surgery Tufts Medical Center, ENT Specialists, Inc, Brockton, Massachusetts, USA.

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.
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June 2020

BRAF and epithelial-mesenchymal transition in papillary thyroid carcinoma - challenging the roles of Snail and E-Cadherin?

Am J Transl Res 2016 15;8(11):5076-5086. Epub 2016 Nov 15.

ENT Specialists, Inc. 825 Washington St # 310, Norwood, MA 02062, UK.

Objective: In papillary thyroid carcinoma (PTC), while the role of BRAF is well established, the contribution of BRAF to epithelial-mesenchymal transition is not.

Study Design/setting: To elucidate the relationship between BRAF, surrogates of epithelial-mesenchymal transition (Snail, E-cadherin) and established histopathologic prognosticators in papillary thyroid carcinoma.

Subjects/methods: In this IRB approved cross-sectional study, 50 cases of archived annotated PTC samples were retrieved and immunohistochemically stained for Snail and E-cadherin protein. A semi-quantitative scoring system (incorporating proportion and intensity) was utilized.

Results: Snail and E-cadherin expression were noted in 44% and 84% of BRAF mutant and, in 29% and 95% of BRAFWT samples, respectively. No statistically significant correlations were noted between Snail, E-cadherin and histopathologic prognosticators. However, a trend was noted between Snail expression and tumor size <5 cm (P=0.07). Statistically significant differences between BRAF mutant and BRAFWT samples were noted in the following groups: conventional (68% vs. 5%) and tall cell (32% vs. 0%) histopathologic variants, extrathyroidal extension (32% vs. 5%), infiltrative growth pattern (80% vs. 48%), presence of desmoplasia (72% vs. 29%), psammona bodies (48% vs. 10%), and cystic change (32% vs. 5%). Among follicular variant of papillary thyroid carcinoma compared to BRAF mutant samples, BRAFWT samples were more commonly of the encapsulated variety (52% vs. 4%), and microcarcinomas (29% vs. 0%) (P<0.001 and =0.007, respectively).

Conclusion: Our findings, supporting the utility of BRAF as a putative therapeutic target in PTC, suggest that the interaction between BRAF and epithelial-mesenchymal transition in papillary thyroid carcinoma is not through induction of the Snail/E-cadherin pathway.
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November 2016

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

Otolaryngol Head Neck Surg 2016 10 31;155(4):564-7. Epub 2016 May 31.

ENT Specialists, Inc, Norwood, Massachusetts, USA Department of Otolaryngology, Tufts Medical Center, Boston, Massachusetts, USA

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.
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October 2016

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

Adv Anat Pathol 2016 Jul;23(4):244-71

*University of Florida College of Medicine, Gainesville, FL †Department of Otolaryngology, Tufts Medical center, Boston, MA ‡Dermatopathology Section, Department of Pathology and Laboratory Medicine, VA Consolidated Laboratories, West Roxbury, MA.

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.
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July 2016

Perineural invasion in cutaneous squamous cell carcinoma: role of immunohistochemistry, anatomical site, and the high-affinity nerve growth factor receptor TrkA.

Hum Pathol 2015 Aug 22;46(8):1209-16. Epub 2015 May 22.

Department of Pathology and Laboratory Medicine (113), VA Medical Center, 1400 VFW PKWY, MA 02132 USA, USA. Electronic address:

Perineural invasion (PNI) has been recently added to the American Joint Committee on Cancer cutaneous squamous cell carcinoma (cSCC) staging criteria as a high-risk tumor characteristic and is purportedly more common in cSCCs of the head and neck (H&N). Expression of the high-affinity nerve growth factor receptor TrkA has been shown to be associated with PNI in noncutaneous neoplasms. Given this, we sought to ascertain the incidence of PNI in cSCCs using double immunostaining (DIS) and to investigate PNI's relationship with TrkA and established histopathologic prognosticators. Fifty-seven cSCCs from the H&N and 53 from non-H&N areas were immunohistochemically analyzed for PNI (DIS with S-100 and p63) and TrkA expression. Comparing H&N versus non-H&N areas, using hematoxylin and eosin, PNI was detected in 11% versus 6% cases, respectively, and, using DIS, in 23% versus 15%, respectively, with significant disagreement between both methods (κ = 0.47; P = .002). There was a 2.33-fold increase in PNI detection with DIS compared to hematoxylin and eosin (95% confidence interval, 1.12-4.87; P = .02). TrkA expression was 1.96 times more frequently observed in cSCCs from the H&N compared to those from non-H&N areas (P = .01). Regardless of site, TrkA expression was associated with decreased degree of differentiation (odds ratio, 6.46; P = .0006) and high-risk morphologic variants (odds ratio, 6.53; P = .002) but not significantly associated with PNI (P = .33). Increased PNI detection with DIS underscores the adjunctive utility of immunohistochemistry in microstaging. Significantly more common TrkA expression in cSCCs of the H&N argues in favor of heterogeneity among SCCs from different anatomical sites.
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August 2015

Radiology quiz case 2. Cervical thymic cyst.

Arch Otolaryngol Head Neck Surg 2008 Oct;134(10):1113, 1115

The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

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October 2008

Radiology quiz case 1. Rhinolith.

Arch Otolaryngol Head Neck Surg 2004 Nov;130(11):1340, 1342-3

New England Medical Center, Boston, Mass, USA.

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November 2004

Paranasal sinus development: a radiographic study.

Laryngoscope 2003 Feb;113(2):205-9

Department of Otolaryngology-Head and Neck Surgery, Tufts-New England Medical Center, 750 Washington Street, New England Medical Center 850, Boston, MA 02111, USA.

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.
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February 2003

Hereditary hemorrhagic telangiectasia: a review of 76 cases.

Laryngoscope 2002 May;112(5):767-73

Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine, New England Medical Center, Boston, MA 02111, USA.

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.
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May 2002