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Background: Otolaryngology-head and neck surgical (OHNS) trainees' operating exposure is supplemented by a combination of didactic teaching, textbook reading, and cadaveric dissections. Conventional teaching, however, may not adequately equip trainees with an understanding of complex visuospatial relationships of the middle ear. Both face and content validation were assessed of a novel three-dimensional (3D) photorealistic virtual ear simulation tool underwent face and content validation as an educational tool for OHNS trainees., Methods: A three-dimensional mesh reconstruction of open access imaging was generated using geometric modeling, which underwent global illumination, subsurface scattering, and texturing to create photorealistic virtual reality (VR) ear models were created from open access imaging and comiled into a educational platform. This was compiled into an educational VR platform which was explored to validate the face and content validity questionnaires in a prospective manner. OHNS post-graduate trainees were recruited from University of Toronto and University of Calgary OHNS programs. Participation was on a voluntary basis., Results: Total of 23 OHNS post-graduate trainees from the two universities were included in this study. The mean comfort level of otologic anatomy was rated 4.8 (± 2.2) out of 10. Senior residents possessed more otologic surgical experience (P < 0.001) and higher average comfort when compared to junior residents [6.7 (± 0.7) vs. 3.6 (± 1.9); P = 0.001]. Face and content validities were achieved in all respective domains with no significant difference between the two groups. Overall, respondents believed OtoVIS was a useful tool to learn otologic anatomy with a median score of 10.0 (8.3-10.0) and strongly agreed that OtoVIS should be added to OHNS training with a score of 10.0 (9.3-10.0)., Conclusions: OtoVIS achieved both face and content validity as a photorealistic VR otologic simulator for teaching otologic anatomy in the postgraduate setting. As an immersive learning tool, it may supplement trainees' understanding and residents endorsed its use., (© 2023. The Author(s).)

Background: There is a growing concern with inappropriate, excessive perioperative blood transfusions. Understanding the influence of low preoperative hemoglobin (Hgb) on perioperative blood transfusion (PBT) in head and neck cancer (HNC) surgery with free flap reconstruction may help guide clinical practice to reduce inappropriate treatment among these patients. The objective is to synthesize evidence regarding the association between preoperative Hgb and PBT among major HNC free flap surgeries., Methods: Terms and synonyms for HNC surgical procedures, Hgb and PBT were used to search MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Reviews from inception to February 2020. Reference lists of included full texts and studies reporting the preoperative Hgb, anemia or hematocrit (exposure) and the PBT (outcome) in major HNC surgery with free flap reconstruction were eligible. Studies examining esophageal, thyroid and parathyroid neoplasms were excluded; as were case reports, case series (n < 20), editorials, reviews, perspectives, viewpoints and responses. Two independent, blinded reviewers screened titles, abstracts and full texts in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was followed. A random-effects model was used to pool reported data. The primary outcome was the proportion of patients who had a PBT. Subgroup analysis examined sources of heterogeneity for perioperative predictors of PBT (age, sex, flap type, flap site and preoperative Hgb). We also examined mean preoperative Hgb in the PBT and no PBT groups., Results: Patients with low preoperative Hgb were transfused more than those with normal Hgb (47.62%, 95% CI = 41.19-54.06, I 2  = 0.00% and 13.92%, 95% CI = 10.19-17.65, I 2  = 20.69%, respectively). None of the predictor variables explained PBT. The overall pooled mean preoperative Hgb was 12.96 g/dL (95% CI = 11.33-14.59, I 2  = 0.00%) and was 13.58 g/dL (95% CI = 11.95-15.21, I 2  = 0.00%) in the no PBT group and 12.05 g/dL (95% CI = 10.01 to 14.09, I 2  = 0.00%) in the PBT group., Conclusions: The heterogeneity between studies, especially around the trigger for PBT, highlights the need for additional research to guide clinical practice of preoperative Hgb related to PBT to enhance patient outcomes and improve healthcare stewardship., (© 2023. The Author(s).)

Background: Physician opioid-prescribing patterns have significant impacts on the current opioid crisis. Patients who use opioids in the postoperative period are at risk of developing chronic postoperative opioid use. This study determined the rate of chronic postoperative opioid use among head and neck cancer patients undergoing primary surgery with free-flap reconstruction. Additionally, this study identified major risk factors associated with the development of chronic postoperative opioid use., Methods: A retrospective chart review was performed for all adults (age ≥ 18 years) undergoing primary head and neck surgical resection with free-flap reconstruction between January 2008 and December 2015. Patients were identified from a prospectively collected database, Otobase™. Data from the provincial drug insurance program were used to capture drug dispensing information to determine chronic opioid use at 3- and 12-months postoperatively. Data extracted from Otobase™ included patient demographics, social habits, clinical stage, pathological stage, type of surgery, and adjuvant treatment., Results: The total cohort was comprised of 212 patients. Chronic opioid use at 3- and 12- months postoperatively was observed in 136 (64%) and 116 (55%) patients, respectively. Of the 212 patients, 85 patients (40%) were identified as preoperative opioid users and 127 were opioid naïve (60%). Of the 85 patients who were preoperative opioid users, 70 (82%) and 63 (77%) patients continued to use opioids 3- and 12-months postoperatively, respectively. The proportion of opioid-naïve patients who were using opioids at 3- and 12-months postoperatively was 52% (66 patients) and 42% (53 patients), respectively. Identified risk factors included preoperative opioid use, prior tobacco use, advanced pathologic T-stage, and adjuvant treatment., Conclusions: Among head and neck cancer patients that have undergone major resection with free-flap reconstruction, the prevalence of chronic postoperative opioid users was considerable. Identified risk factors included preoperative opioid use, prior tobacco use, tumor stage, and adjuvant treatment.

Background: Close margins influence treatment and outcome in patients with oral squamous cell carcinoma (OSCC). This study evaluates 187 cases of surgically treated OSCC regarding the impact of close margins on recurrence-free survival (RFS) and disease-specific survival (DSS)., Methods: Predictors of worsened outcome were identified using Kaplan-Meier analysis and multivariate Cox regression analysis., Results: Tumour size [HR:1.70(0.95-3.08)], nodal status [HR:2.15(1.00-4.64)], presence of extracapsular spread (ECS) [HR:6.36(2.41-16.74)] and smoking history [HR:2.87(1.19-6.86)] were associated with worsened RFS. Similar factors were associated with worsened DSS. Close margins did not influence RFS or DSS., Conclusions: While most conventional risk factors for OSCC conferred a worsened outcome, close margins did not. One explanation for this would be that close margins (< 5 mm) are equivalent to clear margins and the cutoff definition for a close margin should be re-evaluated. Lack of standardized pathology could also reduce accuracy of reporting of close surgical margins.

Background: Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction., Methods: The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made., Results: Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing., Conclusions: Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.

Background: Care pathways (CPs) offer a proven method of systematically improving patient care. CPs are particularly helpful in complex clinical conditions where variation in care is a problem such as patients undergoing major head and neck resection with free flap reconstruction. Although CPs have been used to manage this patient group, most CPs are implemented as part of relatively short-term quality improvement projects. This paper outlines a detailed methodology for designing and delivering a quality management program sustained for 9 years., Methods: We describe a change management approach informed by Kotter's "8 Step Process" that provided a useful framework to guide program development and implementation. We then provide a detailed, step by step description of how such a program can be implemented as well as a detailed summary of time and costs for design, implementation and sustainability phases. An approach to design and delivery of a measurement, audit and feedback system is also provided., Results: We present a summary of resources needed to design and implement a head and neck surgery quality management program. The primary result of this study is a design for a sustainable quality management program that can be used to guide and improve care for patients undergoing major head and neck resection with free flap reconstruction., Conclusions: A change management approach to design and delivery of a head and neck quality management program is practical and feasible.

Following publication of the original article [1], the authors identified incorrect ordering and incorrect files being used for Figs. 1, 2 and 3.

Background: Trainees in Otolaryngology-Head and Neck Surgery must gain proficiency in a variety of challenging temporal bone surgical techniques. Traditional teaching has relied on the use of cadavers; however, this method is resource-intensive and does not allow for repeated practice. Virtual reality surgical training is a growing field that is increasingly being adopted in Otolaryngology. CardinalSim is a virtual reality temporal bone surgical simulator that offers a high-quality, inexpensive adjunct to traditional teaching methods. The objective of this study was to establish the face and content validity of CardinalSim through a national study., Methods: Otolaryngologists and resident trainees from across Canada were recruited to evaluate CardinalSim. Ethics approval and informed consent was obtained. A face and content validity questionnaire with questions categorized into 13 domains was distributed to participants following simulator use. Descriptive statistics were used to describe questionnaire results, and either Chi-square or Fishers exact tests were used to compare responses between junior residents, senior residents, and practising surgeons., Results: Sixty-two participants from thirteen different Otolaryngology-Head and Neck Surgery programs were included in the study (32 practicing surgeons; 30 resident trainees). Face validity was achieved for 5 out of 7 domains, while content validity was achieved for 5 out of 6 domains. Significant differences between groups (p-value of < 0.05) were found for one face validity domain (realistic ergonomics, p = 0.002) and two content validity domains (teaching drilling technique, p = 0.011 and overall teaching utility, p = 0.006). The assessment scores, global rating scores, and overall attitudes towards CardinalSim, were universally positive. Open-ended questions identified limitations of the simulator., Conclusion: CardinalSim met acceptable criteria for face and content validity. This temporal bone virtual reality surgical simulation platform may enhance surgical training and be suitable for patient-specific surgical rehearsal for practicing Otolaryngologists.

Background: Operative endoscopy and flexible fiber-optic in-office tissue biopsy are common techniques to assess suspicious laryngopharyngeal lesions., Methods: The primary outcome was the delay to the initiation of treatment. Secondary outcomes were delay to biopsy, histopathological diagnosis, and assessment at a multidisciplinary oncology clinic. A retrospective analysis was performed to assess the relative delays between these approaches to biopsy of laryngopharyngeal lesions., Results: There were 114 patients in the study cohort; 44 in-office and 70 operative endoscopic biopsies). The mean delay from consultation to biopsy was 17.4 days for the operative endoscopy group and 1.3 days for the in-office group. The mean delay from initial otolaryngology consultation to initiation of treatment was 51.7 days and 44.6 days for the operative endoscopy and in-office groups, respectively., Conclusion: In-office biopsy reduced the time from initial consultation to biopsy. The temporal gains via in-office biopsy did not translate into faster access to treatment. This outcome highlights the opportunity to improve access to treatment for patients with early diagnosis.

Background: Our study quantifies the effectiveness of perioperative pain control in a cohort of patients undergoing major head and neck surgery with free flap reconstruction. Our long-term goal is to improve pain control and thereby increase mobility, decrease postoperative complications and decrease hospital stay., Methods: A retrospective analysis was performed at a tertiary, academic head and neck surgical oncology program in Calgary, Alberta, Canada from January 1, 2015 - December 31, 2015. Pain scores were recorded prospectively. Primary outcomes were frequency of postoperative pain assessments and pain intensity using the numeric rating scale., Results: The cohort included 41 patients. Analysis was limited to pain scores recorded from postoperative days 1-14. There was an average of 7.3 pain measurements per day (SD 4.6, range 1-24) with the most frequent monitoring on postoperative days 1-4. Median pain scores ranged from 0 to 4.5 with the highest median score on postoperative day 6. The daily maximum pain scores recorded ranged from 8 to 10 with scores of 10 recorded on postoperative days 1, 2, 3, 5, 7, 8, and 10. Patients most frequently had inadequate pain control on postoperative days 1, 2, 4, and 5 with the majority occurring on postoperative day 1., Conclusions: Postoperative pain control could be improved at our centre. The frequency of pain assessments is also highly variable. Ongoing measurement, audit, and feedback of analgesic protocol effectiveness is an excellent first step in improving perioperative pain management in patients undergoing major head and neck cancer surgery with free flap reconstruction.

Background: Long operating time and high blood loss contribute to post-surgical morbidity. Therefore, strategies to reduce these factors should to be tested using robust methods. The purpose of this study was to evaluate the impact of using the harmonic scalpel on operating time and blood loss in patients undergoing resection for advanced oral cancer (OSCC)., Methods: Thirty-six adult head and neck cancer patients with advanced OSCC requiring primary tumor resection with uni- or bi- lateral selective neck dissection from July 2012 to September 2014 were randomized to either the control group (traditional surgery) or the experimental group (harmonic surgery). Patients older than 18 years who were able to provide informed consent were eligible. Primary outcomes of interest were: intraoperative blood loss (mL) and operative time (minutes) for the ablative part of the surgery., Results: Mean blood loss in the experimental group was 260 mL versus 403 mL in the control group (p = 0.08). Mean operative time was 140 min in the experimental group and 159 min in the control group (p = 0.2)., Conclusions: In this randomized controlled trial, use of the harmonic scalpel did not effect intraoperative blood loss or OR time in patients undergoing surgery for advanced OSCC., Trial Registration: ClinicalTrials.gov, NCT02017834 .

Background: Indications for performing a prophylactic central neck dissection (pCND) in papillary thyroid cancer (PTC) remain controversial. It is unclear how identification of lymph node (LN) metastases should impact the decision to treat with radioactive iodine (RAI). The goals of this study were to identify indications for performing pCND and identify factors that predict the use of adjuvant RAI., Methods: This was a population based cross-sectional analysis. A prospectively collected database identified 594 patients who underwent total thyroidectomy +/- CND. A multivariate model was constructed to identify indications for pCND and predictors of the use of RAI., Results: 425 CNDs were performed of which 224 were prophylactic. Conventional risk factors (age, tumor size, extra-thyroidal extension) were not associated with performing a pCND. The presence of clinically suspicious lymphadenopathy was the only factor associated with performing CND, thus rendering the CND therapeutic. Positive LNs were retrieved in 39 % of pCND's, upstaging 87 patients. Among all peri-operative predictors of receiving RAI, presence of LN metastases was the strongest predictor [OR = 5.9 (3.7-9.5)], while tumor size was a modest predictor [OR = 1.8 (1.5-2.1)]. Other conventional risk factors did not predict use of adjuvant RAI., Conclusions: Conventional risk factors were not indications for performing a pCND, implying that the decision was based on individual surgeon preference. Performing pCND upstaged 39 % of patients from cN0 to pN1a, increasing the likelihood of receiving RAI 6-fold. Conventional risk factors were not predictors of receiving adjuvant RAI. This highlights the need for a unified approach to performing a pCND and administering RAI.

Background: Head position practice has been shown to influence pill-swallowing ability, but the impact of head position on measures of swallowing outcomes has not yet been studied with fiber-optic endoscopic evaluation of swallowing (FEES). The primary purpose of this study was to determine whether head position impacts penetration-aspiration scale scores and/or post-swallow pharyngeal residue as assessed by FEES. Documenting the incidence of pharyngeal residue and laryngeal penetration and aspiration in a normal population was a secondary goal., Methods: Adults without swallowing difficulties (N = 84) were taught a pill swallowing technique based on learning five head positions and were asked to practice with small, hard candies (e.g., TicTacs) for two weeks. Then they demonstrated swallowing in each of the head positions for two conditions, liquid and purée, while undergoing FEES., Results: Out of 840 examined swallows, one event of aspiration and 5 events of penetration occurred. During practice >50% participants found positions they preferred over the center position for swallowing but head position was not associated with penetration-aspiration scores assessed by FEES. Significant associations and non-significant trends were found between pharyngeal residue and three variables: age, most preferred head position, and least preferred head position., Conclusion: Head position during swallowing (head up) and age greater than 40 years may result in increased pharyngeal residue but not laryngeal penetration or aspiration.

Background: The objective of this study is to evaluate the cost-effectiveness of a postoperative clinical care pathway for patients undergoing major head and neck oncologic surgery with microvascular reconstruction., Methods: This is a comparative trial of a prospective treatment group managed on a postoperative clinical care pathway and a historical group managed prior to pathway implementation. Effectiveness outcomes evaluated were total hospital days, return to OR, readmission to ICU and rate of pulmonary complications. Costing perspective was from the government payer., Results: 118 patients were included in the study. All outcomes demonstrated that the postoperative pathway group was both more effective and less costly, and is therefore a dominant clinical intervention. The overall mean pre- and post-pathway costs are $22,733 and $16,564 per patient, respectively. The incremental cost reduction associated with the postoperative pathway was $6,169 per patient., Conclusion: Implementing the postoperative clinical care pathway in patients undergoing head and neck oncologic surgery with reconstruction resulted in improved clinical outcomes and reduced costs.

Objective: Patients with head and neck cancer frequently present to academic tertiary referral centers with imaging studies that have been performed and interpreted elsewhere. At our institution, these outside head and neck imaging studies undergo formal second opinion reporting by a fellowship-trained academic neuroradiologist with expertise in head and neck imaging. The purpose of this study was to determine the impact of this practice on cancer staging and patient management., Methods: Our institutional review board approved the retrospective review of randomized original and second opinion reports for 94 consecutive cases of biopsy proven or clinically suspected head and neck cancer in calendar year 2010. Discrepancy rates for staging and recommended patient management were calculated and, for the 32% (30/94) of cases that subsequently went to surgery, the accuracies of the reports were determined relative to the pathologic staging gold standard., Results: Following neuroradiologist second opinion review, the cancer stage changed in 56% (53/94) of cases and the recommended management changed in 38% (36/94) of patients with head and neck cancer. When compared to the pathologic staging gold standard, the second opinion was correct 93% (28/30) of the time., Conclusion: In a majority of patients with head and neck cancer, neuroradiologist second opinion review of their outside imaging studies resulted in an accurate change in their cancer stage and this frequently led to a change in their management plan.

Objective: To understand how newer generation multidetector computed tomographic (NGCT) scanner technology (≥ 16 slices) has affected the imaging characteristics of head and neck abscesses., Design: Retrospective chart review., Setting: Tertiary referral centre., Methods: Forty-eight patients with a head and neck abscess who underwent a soft tissue neck computed tomographic (CT) scan were identified from September 1, 2001, to December 1, 2008. The degree of rim enhancement, delta (Δ), was graded using mean Hounsfield units (HU) from five peripheral points and five central points from a representative CT slice. The difference was then calculated and compared between older generation computed tomography (OGCT; < 16 slices) and newer generation multidetector computed tomography (NGCT; ≥ 16 slices) using the Student t-test. A p value < .05 was considered significant., Results: Forty-eight patients met our inclusion criteria. Of these, 20 were scanned with OGCT and 28 were scanned with NGCT. The mean peripheral point values were OGCT  =  78 HU (95% CI 71-86 HU), NGCT  =  74 HU (95% CI 68-80 HU); p  =  .3. The mean central point values were OGCT  =  24 HU (95% CI 21-28 HU), NGCT  =  26 HU (95% CI 21-31 HU), p  =  0.7. The mean delta values (mean peripheral HU--mean central HU) were OGCT  =  52 HU (95% CI 43-61 HU), NGCT  =  46 HU (95% CI 41-52 HU), p  =  .2., Conclusion: There is no significant difference between OGCT and NGCT in the amount of rim enhancement seen on CT scans of head and neck abscesses.

Background: Unilateral hearing loss and audiovestibular symptoms are common in the population and can be associated with retrocochlear tumours such as acoustic neuroma (AN). In order to rule out AN, many patients with asymmetric hearing loss are referred for magnetic resonance imaging (MRI). Recent work with modifications of auditory brainstem response (ABR) protocols has improved the ability of ABR to detect small acoustic tumours. This study presents our initial results using the power spectrum ABR (PSABR) as another tool in detecting patients at higher risk for AN., Methods: A prospective, observational cohort design was employed and a total of 53 subjects were recruited (19 subjects were normal controls and 34 subjects were patients with unilateral audiovestibular symptoms). All subjects underwent complete auditory testing, standard ABR, stacked ABR, and power spectrum ABR. The 34 patients also underwent gadolinium enhanced MRI., Results: Using logistic regression, our data showed that wave I-V latency was most highly predictive of tumour presence or absence. However, both stacked ABR and power spectrum ABR were predictive. Stacked ABR was also able to differentiate symptomatic patients with tumours from those without., Conclusions: This study was not designed to compare PSABR to other more established methods. Rather, our intent was to establish PSABR as a valid and practical addition to other ABR tools. More research is needed to optimize PSABR algorithms, and the method also needs to be tested and validated in larger populations of patients. Early results do indicate that PSABR could be a valid and reliable method of identifying subgroups of patients with unilateral auditory dysfunction who would best benefit from MRI.

Objective: The goal of this study was to describe the incidence, treatment, and outcomes of osteosarcomas in the head and neck over 26 years in the province of Alberta, Canada., Design: Retrospective analysis of 14 patients identified and treated in Alberta between 1974 and 1999. Overall and disease-specific survival were the most important outcomes of interest., Results: The average age was 43 years. The maxilla was the most common primary site. The majority of the patients received surgical treatment in combination with adjuvant chemotherapy. Disease-specific survival was 42% at 2 years and 30.1% at 5 years. Four patients developed osteosarcomas in the field of previous radiation., Conclusions: Osteosarcoma of the head and neck is very aggressive. In our series, mostly high-grade malignancy affected a middle-aged population. Surgical resection is difficult owing to anatomic restraints, and adjuvant chemotherapy should be considered in most patients. The series is notable for the poor outcome, with a 5-year actuarial survival of 30%. This may reflect the lack of a standardized treatment protocol.

Objective: To investigate the role of histone lysine methylation in normal and cancerous head and neck tissues, which will provide novel insight into the pathophysiology of oncogenesis in these tissues., Design: Gene expression profiles from histone lysine methyltransferases (HKMTases) were obtained from UniGene expressed sequence tags (ESTs). HKMTase expression levels in respective tissues were analyzed for elevated expression or altered levels of normal versus human cancers., Setting: UniGene EST data were derived from normal and cancerous human tissues submitted to UniGene., Methods: The expression levels of 47 HKMTases were obtained for 46 normal and 25 cancerous tissues, which included 10 normal and 5 cancerous head and neck tissues. An analysis of expression levels was carried out to identify HKMTases with tissue-specific expression and alteration in head and neck cancer., Main Outcome Measures: Expression levels of HKMTases in normal and cancerous tissues of the head and neck in comparison with other anatomic sites., Results: In 7 of 10 head and neck tissues, we identified HKMTases that were specifically elevated in these tissues in comparison with all 46 normal tissues. In all five head and neck cancers, we identified HKMTases specifically elevated in these tumours. In addition, we identitified HKMTases with altered expression in tumour versus normal head and neck tissues., Conclusions: Normal head and neck tissues have unique epigenetic profiles demarcated by distinct HKMTase gene expression. We identified HKMTases as potentially tissue-specific epigenetic regulators of the head and neck, which could behave as oncogenes or tumour suppressor genes important in malignant transformation of these tissues.

Objectives: Inconsistencies in pathology reporting can contribute to treatment delays and, potentially, inadequate or inappropriate postoperative therapy for patients with malignant disease. Given their importance, there is growing interest in optimizing the reproducibility and readability of pathology reports. The purpose of this study was twofold: (1) to assess the quality and completeness of current head and neck pathology reports in the Calgary Health Region and (2) to examine the effects of a standardized pathology report on clinician comprehension and proposed patient management., Methods: A retrospective review examining the quality and completeness of current head and neck pathology reports was conducted. This was followed by a prospective survey of Canadian head and neck surgeons. Participants were asked to read a traditional freeform pathology report and a standardized pathology report and then complete a brief questionnaire. Comparisons between the responses were then made., Results: Our retrospective analysis demonstrated considerable variation in the completeness of current freeform head and neck pathology reports. The results from our prospective survey establish that our standardized pathology report required significantly less time to read and was preferred by the majority of respondents. In addition, comprehension tended to be higher after reading the standardized pathology report., Conclusion: Standardized pathology reports are known to enhance report quality and consistency. We demonstrate in this study that they require less time to read, are better received, and do not negatively impact reading comprehension, potentially making them an effective and feasible alternative to traditional, freeform pathology reports.