Clinical Focus

  • Residency
  • Otolaryngology-Head & Neck Surgery

Professional Education

  • MBA, Stanford Graduate School of Business (2018)
  • MD, Stanford University School of Medicine (2018)
  • BS, University of California, Los Angeles, Integrative Biology and Physiology (2012)

All Publications

  • The Inferior Turbinate: Role in Normal Respiration and Airway Obstruction CURRENT OTORHINOLARYNGOLOGY REPORTS Thamboo, A., Ayoub, N., Maul, X., Nayak, J. 2021
  • Price Transparency and Compliance With Federal Regulation for Pediatric Tonsillectomy. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Ayoub, N. F., Balakrishnan, K. 2021: 1945998211047146


    OBJECTIVE: To improve hospital price transparency, the Centers for Medicare & Medicaid Services (CMS) requires, as of January 2021, that all hospitals reveal charges for specific items and services. This analysis investigates whether otolaryngology residency-affiliated hospitals have complied with this new regulation, and it evaluates the variability in hospital-reported charges for pediatric tonsillectomy.STUDY DESIGN: Cross-sectional analysis.SETTINGS: Subset of hospitals affiliated with otolaryngology residency programs.METHODS: Hospital websites were searched to determine compliance rates with CMS guidelines by posting a price transparency tool and specific charges for Current Procedural Terminology code 42820 (tonsillectomy and adenoidectomy, <12 years old). Various charges were collected: gross charge, discounted cash price, deidentified minimum and maximum negotiated charges, hospital fees, and physician fees.RESULTS: Overall 104 unique hospitals were analyzed: 81 (78%) provided pricing data, but only 28 (27%) complied with CMS guidelines. The median reported total gross charge was $13,239 (range, $600-$41,957); deidentified minimum negotiated charge, $9222 (range, $337-$25,164); and deidentified maximum negotiated charge, $17,355 (range, $1002-$54,987). Hospital fees (median, $11,900; range, $2304-$38,831) were consistently higher than physician fees (median, $1827; range, $420-$5063). All estimates included a disclaimer stating that values likely underrepresent true prices.CONCLUSION: Hospital compliance with the new regulation remains low, which limits efforts toward improved price transparency. There is wide variability in reported charges for pediatric tonsillectomy and adenoidectomy.

    View details for DOI 10.1177/01945998211047146

    View details for PubMedID 34546823

  • Assessment of Opioid Use and Analgesic Requirements After Endoscopic Sinus Surgery: A Randomized Clinical Trial. JAMA otolaryngology-- head & neck surgery Ayoub, N. F., Choby, G., Turner, J. H., Abuzeid, W. M., Raviv, J. R., Thamboo, A., Ma, Y., Chandra, R. K., Chowdhury, N. I., Stokken, J. K., O'Brien, E. K., Shah, S., Akbar, N., Roozdar, P., Nayak, J. V., Patel, Z. M., Hwang, P. H. 2021


    Importance: The opioid epidemic has generated interest in optimizing opioid prescribing after common surgeries. Recent studies have shown a broad range of analgesic prescription patterns following endoscopic sinus surgery (ESS).Objective: To compare the efficacy of different analgesic regimens after ESS.Design, Setting, and Participants: This multi-institutional, nonblinded randomized clinical trial was conducted at 6 tertiary centers across the US and Canada and included participants who underwent ESS for acute or chronic rhinosinusitis. The study was conducted from March 2019 to March 2020, and the data were analyzed in November to December 2020.Interventions: All participants received acetaminophen, 650 mg, as the first-line analgesic. From there, patients were randomized to either oxycodone rescue (oxycodone, 5 mg, as second-line therapy) or ibuprofen rescue (ibuprofen, 600 mg, as second-line therapy, with oxycodone, 5 mg, reserved for breakthrough pain).Main Outcomes and Measures: Baseline characteristics and disease severity were collected at enrollment. Medication logs, pain scores, and epistaxis measures were collected until postoperative day 7. The primary outcome was the postoperative visual analog scale score for pain. Brief Pain Inventory Pain Severity and Pain Interference Scores were also collected.Results: A total of 118 patients were randomized (62 [52.5%] oxycodone rescue, 56 [47.5%] ibuprofen rescue; mean [SD] age, 46.7 [16.3] years; 44 women [44.0%]; 83 White [83.0%], 7 Black [7.0%], and 7 Asian individuals [7.0%]). After exclusions for loss to follow-up and noncompliance, 51 remained in the oxycodone rescue group and 49 in the ibuprofen rescue group. The groups had similar demographic characteristics and disease severity. Thirty-two (63%) in the oxycodone rescue group had adequate pain management with acetaminophen only, while 19 (37%) consumed at least 1 oxycodone dose. In the ibuprofen rescue group, 18 (16%) required only acetaminophen, 28 (57%) used only acetaminophen and ibuprofen, and the remaining 13 (26%) consumed 1 or more oxycodone doses. The groups had similar average acetaminophen (9.69 vs 7.96 doses; difference, 1.73; 95% CI, -1.37 to 4.83) and oxycodone (1.89 vs 0.77 doses; difference, 1.13; 95% CI, -0.11 to 2.36) use. Both groups had similar postoperative visual analog scale scores. A subanalysis that compared opioids users with nonusers showed clinically significant lower pain scores in nonusers at multiple postoperative points.Conclusions and Relevance: In this randomized clinical trial, most patients who underwent ESS could be treated postoperatively using a nonopioid regimen of either acetaminophen alone or acetaminophen and ibuprofen. Ibuprofen as a second-line therapy did not reduce overall narcotic consumption, but the overall narcotic use was low in both groups.Trial Registration: Identifier: NCT03783702.

    View details for DOI 10.1001/jamaoto.2021.1839

    View details for PubMedID 34351376

  • Pulmonary Embolism and Sigmoid Sinus Thrombosis After Translabyrinthine Vestibular Schwannoma Resection: A Retrospective Case Series. The Annals of otology, rhinology, and laryngology Song, Y., Ayoub, N., Chen, J. X., Alyono, J. C., Welling, D. B. 2021: 34894211036864


    OBJECTIVE: To describe the presentation and treatment of patients developing pulmonary embolism following translabyrinthine approach for vestibular schwannoma resection.METHODS: This was a retrospective case series of patients at 2 academic tertiary medical centers who developed symptomatic pulmonary embolism post-operatively following translabyrinthine approach for vestibular schwannoma resection and were found to have evidence of sigmoid sinus thrombosis.RESULTS: Three patients were identified to have post-operative pulmonary emboli after translabyrinthine approach for vestibular schwannoma resection with sigmoid sinus or internal jugular vein clots in the absence of lower extremity deep vein thrombosis. Caprini scores for these patients were 5 or lower. All patients underwent CT pulmonary angiography and were confirmed to have pulmonary emboli. Two were promptly anticoagulated with heparin drips and transitioned to long-term oral anticoagulation therapy and 1 had delayed anticoagulation. None of these patients suffered from intracranial hemorrhage post-operatively.CONCLUSIONS: Patients undergoing translabyrinthine approach for vestibular schwannoma can develop pulmonary embolism from sigmoid sinus entry or thrombosis. No clear guidelines exist for the management of this complication in the setting of recent craniotomy and the risk of intracranial hemorrhage must be considered prior to initiating anticoagulation.

    View details for DOI 10.1177/00034894211036864

    View details for PubMedID 34353140

  • Oral Corticosteroids Following Endoscopic Sinus Surgery for Chronic Rhinosinusitis Without Nasal Polyposis: A Randomized Clinical Trial. JAMA otolaryngology-- head & neck surgery Chang, M. T., Noel, J. n., Ayoub, N. F., Qian, Z. J., Dholakia, S. n., Nayak, J. V., Patel, Z. M., Hwang, P. H. 2021


    Although oral corticosteroids are commonly prescribed following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) without nasal polyposis, there are little data to suggest that this is a beneficial practice.To assess the efficacy of oral corticosteroids following ESS in CRS without polyps.This prospective double-blinded, placebo-controlled, randomized noninferiority clinical trial conducted in a single academic tertiary rhinology practice included adults with CRS without polyps undergoing ESS. Of 81 patients recruited, 72 completed the study.Patients were randomized into 2 treatment groups: a 12-day postoperative taper of oral prednisone vs matched placebo tablets. All study patients also received a uniform 2-week postoperative regimen of oral antibiotics, fluticasone nasal spray, and saline rinses.The primary outcome measures were Sinonasal Outcome Test-22 (SNOT-22) scores and Lund-Kennedy endoscopy scores, collected preoperatively and postoperatively at 1 week, 1 month, 3 months, and 6 months. Scores were compared between treatment groups at each time point using longitudinal difference between treatment groups and analyzed using 2-way, repeated measures analysis of variance. Secondary outcome measures included treatment-related adverse effects.Overall, 72 patients (mean [SD] age, 49.4 [14.9] years; 36 men, 36 women) completed the study, with 33 in the prednisone arm and 39 in the placebo arm. When comparing longitudinal differences between treatment groups, there was no clinically meaningful difference observed in SNOT-22 total (F[4254] = 1.71, η2 = 0.01 [95% CI, 0.00-0.05]) or Lund-Kennedy scores (F[4247] = 1.23, η2 = 0.02 [95% CI, 0.00-0.50]). In SNOT-22 subdomain analyses, there was no clinically meaningful difference between treatment groups for rhinologic, extranasal rhinologic, ear/facial, or sleep subdomains. However, the prednisone group had worse longitudinal scores for psychological dysfunction compared with the placebo group (F[4254] = 3.18, η2 = 0.05 [95% CI, 0.02-0.09]). Reported adverse effects were similar between the 2 treatment groups.In this randomized clinical trial of patients with CRS without polyps, oral prednisone following ESS conferred no additional benefit over placebo in terms of SNOT-22 total scores, SNOT-22 rhinologic subscores, or Lund-Kennedy endoscopy scores up to 6 months after surgery. Patients receiving prednisone, however, did demonstrate worse SNOT-22 psychologic subdomain scores. These results suggest that the risks of oral corticosteroids may outweigh the benefits; thus use of oral corticosteroids after ESS for CRS without polyps should be carefully Identifier: NCT02748070.

    View details for DOI 10.1001/jamaoto.2021.0011

    View details for PubMedID 33662124

  • Comparison of Parotidectomy With Observation for Treatment of Pleomorphic Adenoma in Adults. JAMA otolaryngology-- head & neck surgery Kligerman, M. P., Jin, M., Ayoub, N., Megwalu, U. C. 2020


    Importance: There is no consensus regarding optimal management of pleomorphic adenoma in adults.Objectives: To compare parotidectomy with observation for the management of pleomorphic adenoma in patients 50 years or older by age.Design and Setting: This decision analytical model was performed from November 21, 2019, to June 15, 2020, using a Markov model. Model variables and ranges were selected based on a literature review. A 1-way sensitivity analysis was performed to evaluate the age threshold at which each algorithm, either upfront elective parotidectomy or observation, would be favored. A Monte Carlo probabilistic sensitivity analysis using variable ranges was then performed 5 times with patients in the model assigned a starting age of 50, 60, 70, 80, and 90 years to assess how age at diagnosis would be associated with the model results.Main Outcomes and Measures: Model outcomes were measured with quality-adjusted life-years (QALYs).Results: In the study models, the age thresholds at which observation became more beneficial than parotidectomy were 88.5 years for patients with superficial lobe tumors (5.37 QALYs in favor of parotidectomy below this age, and 5.37 QALYs in favor of observation above this age) and 83.4 years for patients with deep lobe tumors (7.51 QALYs in favor of surgery below this age, and 7.51 QALYs in favor of observation above this age). There was no significant difference in outcomes between parotidectomy and observation among patients aged 70 to 80 years.Conclusions and Relevance: This study suggests that the outcomes associated with parotidectomy and observation are similar at 70 years or older among patients with pleomorphic adenoma and that observation may be the favorable treatment in that age group.

    View details for DOI 10.1001/jamaoto.2020.2944

    View details for PubMedID 32970111

  • Nasal Symptoms Following Laryngectomy: A Cross-sectional Analysis. American journal of rhinology & allergy Ayoub, N., Kearney, A., Sayyid, Z. N., Erickson-DiRenzo, E., Jeffrey, C., Hwang, P. H. 2020: 1945892420901631

    View details for DOI 10.1177/1945892420901631

    View details for PubMedID 31964149

  • Facial Paralysis and Communicative Participation: The Importance of Facial Symmetry at Rest. The Annals of otology, rhinology, and laryngology Ayoub, N. F., Abdelwahab, M. n., Zhang, M. n., Ma, Y. n., Stranberg, S. n., Okland, T. S., Pepper, J. P. 2020: 3489420912446


    There is a paucity of research devoted to understanding the communication restrictions encountered by facial paralysis patients. We aim to explore the relationship between patient-reported restrictions in communicative participation and objective facial paralysis severity using validated scales of facial movement.We performed a pilot retrospective study using a consecutive series of adult patients with a diagnosis of unilateral facial paralysis. In addition to baseline demographics, subjects were evaluated using the Communicative Item Participation Bank Short Form (CPIB), Electronic Facial Assessment by Computer Evaluation (eFACE), and Sunnybrook Facial Grading System (SFGS).Twenty patients were included, 10 (50%) of whom were female with a mean age of 61 ± 13 years and mean duration of facial paralysis of 53 ± 82 months. The mean CPIB score was 14.6 ± 10.0 (range 0-29) and was comparable to scores of patients with conditions known to cause significant communicative disability. The mean eFACE scores were 67.4 ± 29.2, 44.2 ± 30.1, and 73.8 ± 30.0 for the static, dynamic, and synkinesis domains, respectively, with a composite smile score of 58.5 ± 16.9. After adjusting for age, gender, and duration of facial paralysis, significant moderate correlations were observed between the CPIB and the static eFACE domain (r = -0.51, P = .03) and smile composite score (r = 0.48, P = 0.0049), in addition to between the CPIB and SFGS synkinesis domain (r = 0.48, P = 0.04).Patients with unilateral facial paralysis experience significant limitations in communicative participation. These restrictions demonstrate moderate to strong correlations with objective assessments of facial paralysis and quality of life measures. Communicative participation may be a helpful means of tracking response to treatment.IV.

    View details for DOI 10.1177/0003489420912446

    View details for PubMedID 32192355

  • Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy. The Laryngoscope Beswick, D. M., Ayoub, N. F., Mace, J. C., Mowery, A., Hwang, P. H., Smith, T. L. 2019


    OBJECTIVES/HYPOTHESIS: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS.STUDY DESIGN: Retrospective outcomes research.METHODS: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed.RESULTS: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P <.001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P =.031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P =.005).CONCLUSIONS: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS.LEVEL OF EVIDENCE: 2c Laryngoscope, 2019.

    View details for DOI 10.1002/lary.28460

    View details for PubMedID 31837149

  • Correlation between extent of sinus surgery, radiographic disease, and postoperative outcomes. Rhinology Ayoub, N., Walgama, E., Thamboo, A., Chitsuthipakorn, W., Patel, Z. M., Nayak, J. V., Hwang, P. H. 2019


    BACKGROUND: The extent of endoscopic sinus surgery (ESS) required for optimal outcomes in chronic rhinosinusitis (CRS) is undefined. We evaluated whether concordance between the extent of surgery and degree of radiographic disease influences postoperative outcomes.METHODS: 247 CRS patients who underwent ESS were retrospectively assigned a concordance score reflecting the similarity between the extent of surgery and degree of radiographic disease. 0 points were assigned when sinusotomy was performed on a diseased sinus, or no sinusotomy was performed on a nondiseased sinus; plus 1 for sinusotomy on a nondiseased sinus; and -1 for a diseased sinus left unopened. The total possible score ranged from minus 10 to plus 10. Patients were divided into 5 subgroups according to variance from complete concordance. SNOT-22 scores and revision rates were compared at 6 and 24 months.RESULTS: All five subgroups had similar preoperative SNOT-22 scores and improved at 6 months postoperatively. At 6 months postoperatively, the most conservatively operated and most extensively operated subgroups each achieved equivalent improvements in SNOT-22 as the completely concordant subgroup. At 24 months, the most extensively operated subgroup had a 12.5-point smaller improvement in SNOT-22 scores compared to the completely concordant subgroup. Multivariate analysis showed no association between concordance score and revision rate.CONCLUSIONS: Symptom improvement and revision rates after ESS do not appear to correlate with the degree of concordance between extent of surgery and radiographic disease. More extensive surgery than indicated by CT confers neither greater symptomatic improvement nor long-term detriment.

    View details for DOI 10.4193/Rhin19.213

    View details for PubMedID 31671433

  • Static endoscopic swallow evaluation in children. The Laryngoscope Meister, K. D., Okland, T., Johnson, A., Galera, R., Ayoub, N., Sidell, D. R. 2019


    OBJECTIVES: Static Endoscopic Evaluation of Swallowing (SEES) has been demonstrated to have a strong correlation with the Videofluoroscopic Swallow Study (VFSS) in adults. In children, Fiberoptic Endoscopic Evaluations of Swallow (FEES) are frequently performed to avoid repeated VFSS; however, a subset of the population does not tolerate FEES. The purpose of this study was to evaluate the utility of a modified SEES in children.METHODS: Charts of 50 consecutive patients who underwent FEES evaluations were reviewed. Patients age 3 months to 12years undergoing SEES, FEES, and VFSS were extracted. We compared a binary assessment of outcome on SEES versus VFSS as the diagnostic standard to report characteristics, including sensitivity, specificity, and positive and negative predicted value.RESULTS: A total of 36 patients met all inclusion criteria (mean age 2.8years). Using the VFSS as the diagnostic standard, residue seen on SEES had a sensitivity of 80.0%, specificity of 85.7%, a positive predictive value of 88.9%, and a negative predictive value of 75.0% for predicting deep penetration or aspiration.CONCLUSION: SEES may be helpful for developing an initial diagnostic impression and may serve as a platform for patient and caregiver counseling. In children who are unable to cooperate with FEES, SEES may provide clinical insight in predicting an abnormal swallow study; however, a normal SEES was less reliable in predicting a safe swallow on subsequent VFSS in this patient population.LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

    View details for DOI 10.1002/lary.28263

    View details for PubMedID 31448817

  • Implementation of a targeted HPV educational program in a population with HIV. World journal of otorhinolaryngology - head and neck surgery Ayoub, N., Sunwoo, J. B., Starmer, H. M. 2019; 5 (2): 105–11


    Patients living with human immunodeficiency virus (PLWH) are at higher risk of developing human papillomavirus (HPV)-associated malignancies. This prospective, longitudinal study evaluated the baseline knowledge of PLWH regarding HPV infection and its association with head neck cancer, and it aimed to determine whether a focused educational session could promote both short- and long-term knowledge acquisition in this population. Twenty-seven subjects participated in an interactive educational session and completed pre-test and immediate and delayed (4-month) post-test questionnaires. When compared to their pre-test answers, subjects demonstrated significant improvements in all 28 questions immediately following education. Knowledge preservation was demonstrated 4 months after initial evaluation, with subjects performing significantly better than their pre-test scores in 24 of the original 28 questions. These results suggest that short, focused, educational programs for PLWH may promote a better understanding of HPV's association with human immunodeficiency virus (HIV) and HPV risk factors, methods of transmission, and prevention.

    View details for DOI 10.1016/j.wjorl.2018.09.006

    View details for PubMedID 31334489

  • The Horizon Sign and Frontal Bar: Two Topographic Landmarks to Confirm Endoscopic Frontal Sinusotomy OTOLARYNGOLOGY-HEAD AND NECK SURGERY Walgama, E. S., Thamboo, A., Tangbumrungtham, N., Ayoub, N., Patel, Z. M., Nayak, J. V. 2019; 160 (4): 740–43
  • The Horizon Sign and Frontal Bar: Two Topographic Landmarks to Confirm Endoscopic Frontal Sinusotomy. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Walgama, E. S., Thamboo, A., Tangbumrungtham, N., Ayoub, N., Patel, Z. M., Nayak, J. V. 2019: 194599818825472


    Confirming a thorough dissection of the frontal sinus during endoscopic sinus surgery can be challenging, and some surgeons would benefit from reliable topographic landmark identification to ensure completion of this sinus dissection. We defined (1) the "horizon sign" as the curvilinear shadow of the posterior table cast superiorly upon the anterior table of the frontal sinus at the acute angle of their meeting point and (2) the "frontal bar" as a sagittal septation at the union of the anterior/posterior tables. A cadaveric study, followed by an intraoperative consecutive case series, was performed to evaluate these 2 landmarks as indicators of complete dissection. The horizon sign was extremely reliable, identified in 100% of cadaveric frontal sinuses and intraoperative frontal sinuses. The frontal bar was present in only 67% of frontal sinuses by computed tomography. In live patients, the sensitivity and specificity of the frontal bar were 62% and 95%, respectively.

    View details for PubMedID 30691380

  • Appropriateness criteria predict outcomes for sinus surgery and may aid in future patient selection LARYNGOSCOPE Beswick, D. M., Mace, J. C., Soler, Z. M., Ayoub, N. F., Rudmik, L., DeConde, A. S., Smith, T. L. 2018; 128 (11): 2448–54


    Appropriateness criteria to determine surgical candidacy for chronic rhinosinusitis (CRS) have recently been described. This study stratified patients who underwent endoscopic sinus surgery (ESS) according to these new appropriateness criteria and evaluated postoperative improvements among appropriateness categories.Adult patients with uncomplicated CRS electing ESS were prospectively enrolled in a multi-institutional cohort study between March 2011 and June 2015 to assess outcomes. Subsequently, appropriateness criteria that consider preoperative medical therapy, 22-item SinoNasal Outcome Test (SNOT-22) scores, and Lund-Mackay computed tomography scores were retrospectively applied.A total of 92.6% (436 of 471) were categorized as "appropriate" ESS candidates, 3.8% (18 of 471) as "uncertain," and 3.6% (17 of 471) as "inappropriate." Among uncertain patients, two-thirds (12 of 18) had identifiable reasons for undergoing ESS, most commonly oral corticosteroid intolerance (n = 6). Postoperative follow-up was available for 79% (n = 372). Clinically significant SNOT-22 improvements occurred in both appropriate and uncertain groups (all P < 0.050) but not among the inappropriate group. The inappropriate group reported less mean improvement in SNOT-22 total score compared to appropriate (P = 0.008) and uncertain (P = 0.006) groups.The vast majority of patients (∼93%) who underwent ESS in a multi-institutional research program were identified as appropriate candidates for surgical intervention, as defined by current appropriateness criteria. Valid considerations frequently exist for offering ESS to patients categorized as uncertain. Appropriate and uncertain candidates report similar, clinically significant SNOT-22 improvements following surgery. Patients classified as inappropriate reported significantly less improvement following ESS. Surgical appropriateness criteria may assist in predicting outcomes of ESS.2b. Laryngoscope, 2448-2454, 2018.

    View details for PubMedID 29756211

    View details for PubMedCentralID PMC6235736

  • Correlations Between Cystic Fibrosis Genotype and Sinus Disease Severity in Chronic Rhinosinusitis LARYNGOSCOPE Abuzeid, W. M., Song, C., Fastenberg, J. H., Fang, C. H., Ayoub, N., Jerschow, E., Mohabir, P. K., Hwang, P. H. 2018; 128 (8): 1752–58


    Cystic fibrosis (CF) patients commonly develop chronic rhinosinusitis (CRS). The impact of the most common cystic fibrosis transmembrane conductance regulator (CFTR) mutation, F508del, on the severity of sinonasal disease remains inconclusive. The objective of this study is to evaluate the impact of CFTR genotype functional classification on sinonasal disease severity in patients with CRS.Retrospective chart review of patients with CF who underwent endoscopic sinus surgery for chronic rhinosinusitis from 1998 to 2015. Patients were divided into high- or low-risk genotypes based on standardized CFTR gene functional classification. The primary outcome was the 22-item Sino-Nasal Outcome Test (SNOT-22) score. Secondary outcomes included endoscopic scores, extent of surgery performed, presence of polyposis, number of revision surgeries, and Lund-MacKay computed tomography scores.Thirty-eight patients harbored a high-risk CFTR genotype, and 11 had a low-risk genotype. On bivariate analysis, there was no association between CFTR genotype risk stratification and measures of preoperative disease severity or postoperative outcomes. There were no associations between genotype risk stratification and outcome variables on multivariate linear regression, adjusted for age and gender. There were significant improvements in several SNOT-22 subdomains before and after endoscopic sinus surgery (P < 0.05), but the magnitude of improvement was not significantly different on the basis of CFTR genotype risk stratification.High-risk CFTR genotypes are not associated with worse sinonasal disease severity or postoperative symptom control than low-risk CFTR genotypes after adjusting for confounding factors.Level 4. Laryngoscope, 1752-1758, 2018.

    View details for PubMedID 29193105

  • 'Addressed to you not as a smoker... but as a doctor': doctor-targeted cigarette advertisements in JAMA ADDICTION Jackler, R. K., Ayoub, N. F. 2018; 113 (7): 1345–63

    View details for DOI 10.1111/add.14151

    View details for Web of Science ID 000434634200028

  • Nose blowing after endoscopic sinus surgery does not adversely affect outcomes LARYNGOSCOPE Ayoub, N., Chitsuthipakorn, W., Nayak, J. V., Patel, Z. M., Hwang, P. H. 2018; 128 (6): 1268–73

    View details for DOI 10.1002/lary.26907

    View details for Web of Science ID 000434179100010

  • Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy EUROPEAN ARCHIVES OF OTO-RHINO-LARYNGOLOGY Beswick, D. M., Santa Maria, C., Ayoub, N. F., Capasso, R., Santa Maria, P. 2018; 275 (2): 569–78


    To provide histological evidence to investigate a theory for post-tonsillectomy secondary hemorrhage (PTH) in a mouse model and to evaluate the potential for heparin-binding epidermal growth factor-like growth factor (HB-EGF) treatment on wound healing in this model.A prospective randomized single-blinded cohort study. A uniform tongue wound was created in 84 mice (day 0). Mice were randomized to HB-EGF (treatment, n = 42) or saline (control, n = 42). In treatment mice, HB-EGF 5 µg/ml was administered intramuscularly into the wound daily (days 0-14). In control mice, normal saline was administered daily. Three mice from each group were sacrificed daily through day 14 and the wounds evaluated histologically by blinded reviewers.Key stages of wound healing, including keratinocyte proliferation and migration, wound contraction, epithelial separation, and neoangiogenesis, are defined with implications for post-tonsillectomy wound healing. Epithelial separation (59 vs. 100%, p = 0.003) and wound reopening (8 vs. 48%, p < 0.001) were reduced with HB-EGF. Epithelial thickness (220 vs. 30 µm, p = 0.04) was greater with HB-EGF. Wound closure (days 4-5 vs. day 6, p = 0.01) occurred earlier with HB-EGF.In healing of oral keratinocytes on muscle epithelial separation secondary to muscle, contraction occurs concurrently with neoangiogenesis in the base of the wound, increasing the risk of hemorrhage. This potentially explains why post-tonsillectomy secondary hemorrhage occurs and its timing. HB-EGF-treated wounds showed greater epithelial thickness, less frequent epithelial separation and wound reopening, and earlier wound closure prior to neovascularization, suggesting that HB-EGF may be a potential preventative therapy for PTH.NA-animal studies or basic research.

    View details for PubMedID 29188436

  • 'Addressed to you not as a smoker… but as a doctor': doctor-targeted cigarette advertisements in JAMA. Addiction (Abingdon, England) Jackler, R. K., Ayoub, N. F. 2018


    During the mid-20th century tobacco companies placed advertisements in medical journals to entice physicians to smoke their brand and, more importantly, to recommend it to their patients. They have been little studied, in part because advertising sections in medical journals are almost universally discarded before binding. This study aimed to define the themes and techniques used in doctor-targeted tobacco advertisements that appeared in American medical journals in the mid-20th century and determine the motivations and tactics of the tobacco industry in engaging the medical profession in this way.Doctor-targeted tobacco advertisements from JAMA and the New York State Medical Journal appearing between 1936 and 1953 were studied. These were obtained from the New York Academy of Medicine and the UCSF Truth database of tobacco industry documents. Content analysis of advertising slogans and imagery was conducted. Using internal tobacco industry documents, we examined the relationship between tobacco advertisers and medical journals.Among the 519 doctor-targeted advertisements, 13 brands were represented, with two (Philip Morris and Camel) accounting for 84%. Correspondence between tobacco advertisers and medical journal editors reveals the potent influence of revenue to the sponsoring society and personal compensation derived from consulting arrangements. Content analysis of the advertisements revealed much flattery of doctors and arguments professing the harmlessness of the company's brand.Analysis of doctor-targeted tobacco advertisements in American medical journals from 1936 to 1953 suggest that tobacco companies targeted physicians as a potential sales force to assuage the public's fear of health risks and to recruit them as allies against negative publicity. Tobacco companies also appeared to try, through the substantial advertising revenue passed by journals to their parent medical societies, to temper any possible opposition by organized medicine.

    View details for PubMedID 29417649

  • Efficacy of endoscopic sinus surgery for chronic rhinosinusitis following primary radiotherapy and concurrent chemotherapy for nasopharyngeal carcinoma INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Ayoub, N., Walgama, E., Thamboo, A., Nayak, J. V., Hwang, P. H. 2017; 7 (11): 1045–51


    Chronic rhinosinusitis (CRS) is a downstream complication following radiotherapy or chemoradiation for nasopharyngeal carcinoma (NPC). Endoscopic sinus surgery (ESS) is an accepted therapy for medically refractory CRS, but its efficacy in addressing CRS symptoms in patients with previously irradiated NPC is unclear.All patients at the Stanford Sinus Center with a history of radiation therapy or chemoradiation for NPC between 2006 and 2015 were reviewed. Patients without antecedent CRS prior to NPC treatment (n = 26) were retrospectively divided into 2 cohorts based on whether they developed postirradiation CRS and underwent ESS (surgical group, n = 13) or did not develop CRS (control, n = 13). Demographic and clinical characteristics were collected, and temporal changes in 22-item Sino-Nasal Outcome Test (SNOT-22) score were compared.The median time following primary irradiation to initial presentation was 6.8 and 6.5 years in the surgical and control groups, respectively. The surgical cohort had statistically greater baseline SNOT-22 scores than the control group (45 vs 14, p = 0.0198). At 6 to 12 months postoperatively, the surgical group demonstrated statistically significant and clinically meaningful improvements in SNOT-22 scores when compared to controls (15-point decrease vs 0, p = 0.0040), ultimately resulting in similar SNOT-22 scores for both groups (28 vs 18, p = 0.3687). The rhinologic, extranasal, and ear/face subdomain scores of the surgical group were significantly greater than those of the control group preoperatively (rhinologic: p = 0.0010; extranasal: p = 0.0179; ear/face: p = 0.0068), but these disparities resolved postoperatively (rhinologic: p = 0.1461; extranasal: p = 0.3131; ear/face: p = 0.3401).ESS appears to effectively manage recalcitrant CRS symptoms in patients previously treated with radiation therapy and concurrent chemotherapy for NPC.

    View details for PubMedID 28806502

  • Radioanatomic Study of the Greater Palatine Canal Relevant to Endoscopic Endonasal Surgical Landmarks OTOLARYNGOLOGY-HEAD AND NECK SURGERY Ayoub, N., Thamboo, A., Hwang, P. H., Walgama, E. S. 2017; 157 (4): 731–36


    Objective A radioanatomic study of surgically relevant variations in the greater palatine canal (GPC) on computed tomography (CT) was performed to determine susceptibility during endoscopic endonasal procedures. Study Design Blinded radioanatomic analysis. Setting Tertiary university hospital. Subjects and Methods Fifty consecutive paranasal CT scans (100 sides) were analyzed. Measurements were standardized to landmarks such as the inferior turbinate (IT) and floor of the nasal cavity (FNC) to assess variability and vulnerability of the nerve. Measurements included (1) incidence of maxillary sinus pneumatization posterior to the GPC, (2) distance from the posterior wall of the maxillary sinus to the GPC at the IT and FNC, (3) width of bone containing the GPC, (4) incidence of medial GPC dehiscence, and (5) angle of the GPC extending from the IT to FNC. Results Ninety-one percent of maxillary sinuses were pneumatized posterior to the GPC. The distance from the posterior wall of the maxillary sinus to the GPC was 2.8 ± 1.7 mm (range, -2.3 to 5.9) at the posterior attachment of the IT and 4.1 ± 3.1 mm (range, -6.3 to 11.9) at the FNC. The width of bone containing the GPC was 3.3 ± 1.3 mm (range, 1-8.9), and the medial bony GPC was dehiscent in 38% of cases. In the sagittal plane, the angle of the GPC between the IT and the FNC was 31.9 ± 6.9 degrees (range, 10.8-45). Conclusion The GPC has considerable anatomic variability relative to important surgical landmarks in endoscopic procedures. Preoperative review of CTs to assess vulnerability may prevent postoperative complications.

    View details for PubMedID 28608764

  • The impact of developing a speech and swallow rehab program: Improving patient satisfaction and multidisciplinary care. Laryngoscope Starmer, H. M., Ayoub, N., Byward, C., Kizner, J., Le, Q., Hara, W., Holsinger, F. C. 2017


    The objective of this study was to evaluate the impact of developing an integrated head and neck cancer speech and swallowing rehabilitation program on physician/team focus on functional outcomes.Prospective cross-sectional design.Surveys regarding physician behavior and patient satisfaction with speech and swallowing were administered in an academic oncology practice prior to and 1 year following establishment of a dedicated head and neck speech and swallowing rehabilitation program. Participants included new and established head and neck cancer patients recruited consecutively. The primary outcome was physician behavior regarding speech and swallowing outcomes (as measured by discussion of function, providing suggestions regarding function, and referral to speech-language pathology services).A total of 199 surveys were returned at the first time point and 271 at the second. Demographic variables were comparable between the two groups. The later cohort was more likely to report team discussion and suggestions regarding speech and swallowing function than the former (P < .001, 95% confidence interval [CI]: -0.775 to -0.265; P < .001, 95% CI: -0.928 to -0.035, respectively). Although there was no significant difference between the groups in regard to satisfaction with speech (P = .07), more favorable satisfaction with swallowing was reported by the later cohort (P = .028, 95% CI: -0.531 to -0.029).Integration of speech and swallowing rehabilitation into head and neck cancer programs is associated with increased physician focus on functional outcomes and greater patient satisfaction in regard to swallowing function. We advocate for standard integration of such services into the multidisciplinary head and neck cancer care team.4. Laryngoscope, 2017.

    View details for DOI 10.1002/lary.26695

    View details for PubMedID 28561453

  • Determinants and outcomes of upfront surgery versus medical therapy for chronic rhinosinusitis in cystic fibrosis. International forum of allergy & rhinology Ayoub, N., Thamboo, A., Habib, A., Nayak, J. V., Hwang, P. H. 2017


    The indications for surgical management of chronic rhinosinusitis (CRS) in patients with cystic fibrosis (CF) are poorly defined. In this study we compare outcomes of medical versus surgical treatment and examine trends associated with the transition from medical to surgical therapy in CF patients.One hundred thirty-six patients with CF referred to a tertiary rhinology practice were retrospectively divided into 3 cohorts: Medical, Upfront Surgery, or Crossover, if they converted from medical to surgical management. The 22-item Sino-Nasal Outcome Test (SNOT-22) and pulmonary function test (PFT) data were assessed up to 48 months.Compared to patients initially managed medically (n = 90), those who pursued upfront surgery (n = 46) had a greater incidence of nasal polyposis (p = 0.0011), prior sinus surgery (p = 0.0025), lower percent-predicted forced expiratory volume in 1 second (%FEV1 ) (p = 0.0063), and higher Lund-Mackay (p = 0.0025) and SNOT-22 (p = 0.0229) scores. Within the medical group, 35.5% converted to surgery after a mean of 14.3 months. Crossover (n = 32) was associated with a 6.1-point increase in SNOT-22 and a 4.5% deterioration in %FEV1 . Despite worsened symptom severity, the Crossover cohort ultimately achieved similar postoperative SNOT-22 scores (p = 0.831) and %FEV1 (p = 0.114) as those who underwent upfront surgery. Although the Medical cohort had the lowest baseline SNOT-22 scores (p < 0.001), surgery at any time normalized scores to the same baseline level (p = 0.652). Neither medical therapy nor surgery improved PFTs.Surgery effectively reduces CRS-related symptoms in CF patients but may not improve pulmonary function. In patients who first pursue medical therapy, symptomatic decline may prompt eventual conversion to surgery. Patients who delay surgery may achieve similar outcomes as those who pursue surgery upfront.

    View details for DOI 10.1002/alr.21912

    View details for PubMedID 28218486

  • Nose blowing after endoscopic sinus surgery does not adversely affect outcomes. The Laryngoscope Ayoub, N. n., Chitsuthipakorn, W. n., Nayak, J. V., Patel, Z. M., Hwang, P. H. 2017


    Patients frequently are advised to abstain from nose blowing following endoscopic sinus surgery (ESS), despite a lack of evidence supporting this recommendation. This randomized study assessed whether nose blowing in the first postoperative week affects subjective and objective clinical outcomes.Forty patients undergoing ESS were randomized into an interventional arm in which patients blew their nose at least twice daily for the first 7 postoperative days, or a control arm in which patients refrained from nose blowing. All patients were allowed to blow their nose after 7 days. The frequency and degree of epistaxis was documented by daily diary and visual analog scale (VAS). At 1 and 4 weeks postoperatively, Nasal Obstruction Symptom Evaluation (NOSE) and Sino-Nasal Outcome Test-22 (SNOT-22) were collected, and endoscopies were recorded for blinded Lund-Kennedy scale scoring.There were no differences between the two groups in terms of frequency and duration of bleeding events, VAS epistaxis scores, SNOT-22 scores, and NOSE scores at every postoperative timepoint. Lund-Kennedy scores also were similar at the 1-week (P = 0.0762) and 4-week (P = 0.2340) postoperative visits, but the nose-blowing group had improved nasal discharge subscores at the first (P = 0.0075) and second (P = 0.0298) postoperative visits.Nose blowing after ESS does not appear to measurably improve symptoms of nasal congestion or general sinonasal quality of life, nor does it seem to adversely affect the frequency or severity of postoperative epistaxis during the first postoperative week. Judicious nose blowing may be permissible immediately after uncomplicated ESS.1b. Laryngoscope, 2017.

    View details for PubMedID 29068050

  • Evidence for a 'preinvasive' variant of fungal sinusitis: Tissue invasion without angioinvasion. World journal of otorhinolaryngology - head and neck surgery Paknezhad, H. n., Borchard, N. A., Charville, G. W., Ayoub, N. F., Choby, G. W., Thamboo, A. n., Nayak, J. V. 2017; 3 (1): 37–43


    Clinical experience has suggested the existence of an intermediate form of fungal sinusitis between the categories of non-invasive fungal sinusitis (non-IFS) and invasive fungal sinusitis (IFS). This fungal sinusitis variant demonstrates unhealthy mucosa by endoscopy with fungal invasion, but lacks angioinvasion microscopically, representing what clinically behaves as a 'pre-invasive' subtype of fungal sinusitis. Unlike non-IFS disease, patients with pre-invasive fungal sinusitis were still felt to require anti-fungal medications due to histologic presence of invasive fungus. While sharing some clinical features of IFS, these 'intermediate' patients were successfully spared extended and repeated surgical debridements given the microscopic findings, and have been successfully treated with shorter courses of antifungal therapy. These select patients have had favorable outcomes when managed in a judicious and semi-aggressive manner, in an undefined zone between the treatments for routine fungal ball and aggressive IFS.

    View details for PubMedID 29204577

  • Leading-Brand Advertisement of Quitting Smoking Benefits for E-Cigarettes. American journal of public health Ramamurthi, D., Gall, P. A., Ayoub, N., Jackler, R. K. 2016; 106 (11): 2057-2063


    To provide regulators and the US Food and Drug Administration with a description of cessation-themed advertising among electronic cigarette (e-cigarette) brands.We performed a content analysis of 6 months (January through June 2015) of advertising by e-cigarette brands on their company-sponsored social media channels and blogs as well as user-generated content (testimonials) appearing within brand-sponsored Web sites. An explicit claim of cessation efficacy unambiguously states that e-cigarettes help in quitting smoking, and implicit claims use euphemisms such as "It works." We selected a cohort of 23 leading e-cigarette brands, either by their rank in advertising spending or their prevalence in Internet searches.Among leading e-cigarette brands, 22 of 23 used cessation-themed advertisements. Overall, 23% of the advertisements contained cessation claims, of which 18% were explicit and 82% were implicit.Among leading e-cigarette advertisers, cessation themes are prevalent with implicit messaging predominating over explicit quit claims.These results can help the Food and Drug Administration clarify whether tobacco products should be regulated as drugs with therapeutic purpose or as recreational products.

    View details for PubMedID 27631743

  • Distinguishing computed tomography findings in patients with empty nose syndrome. International forum of allergy & rhinology Thamboo, A., Velasquez, N., Ayoub, N., Nayak, J. V. 2016; 6 (10): 1075-1082


    Given the lack of basic diagnostic criteria for empty nose syndrome (ENS), we sought to define whether consistent radiographic characteristics could be identified to aid in the development of such criteria.Computed tomography (CT) scans were collected from 65 patients diagnosed with ENS, patients with a history of submucosal inferior turbinate reduction (ITR) without ENS, and patients without a history of sinonasal procedures. Measurements were taken at the level of the nasolacrimal duct, including the inferior turbinate (IT) mucosal thickness, and the widest distances between septum-IT, nasal floor-IT, lateral nasal wall-IT, and septum-lateral nasal wall. The thickest sites of soft tissue density of the nasal cavity floor, septum, and lateral wall were also measured in the anterior, central, and posterior segments of the nasal cavity.The mucosal thickness of both the central and posterior segments of the septum in ENS subjects was significant when compared to ITR without ENS (p < 0.01) and control subjects (p < 0.01). Constant landmarks such as the agger nasi, the presence of middle turbinate, and the nasolacrimal duct defined a simple set of landmarks that can serve as the start of the central-nasal region, and a cutoff >2.64 mm and >1.32 mm in the central nasal and posterior nasal regions provided the highest likelihood of differentiating ENS patients from ITR without ENS patients.These findings provide evidence there are 2 objective radiographic changes (central and posterior septal mucosa) that suggest ENS patients can be discriminated based on mucosal CT findings.

    View details for DOI 10.1002/alr.21774

    View details for PubMedID 27409044

  • Objective and subjective scar aesthetics with topical Manuka honey post-thyroidectomy: A randomized control study. World journal of otorhinolaryngology - head and neck surgery Thamboo, A. n., Mulholland, G. n., Matthews, K. n., Ayoub, N. n., Anderson, D. n. 2016; 2 (4): 203–7


    Leptospermum Honey (Manuka honey) has proven to be effective in improving acute and chronic wound healing presumably due to its antibacterial and anti-inflammatory properties. The aim is to determine if Manuka honey decreases scar formation and results in a cosmetically appealing scar.A prospective single-blinded randomized control trial was performed. All patients received an 8 cm incision. Patients randomized to honey treatment were instructed to apply Manuka honey paste topically to the incision site once per day post surgery for 4 weeks. The patients' scar was then analyzed objectively by a blinded observer and subjectively at 4 and 8 weeks postoperatively. The primary outcome measure used was the Patient and Observer Scar Assessment Scale (POSAS).A total of 21 patients completed the entire scar analysis (honey treatment = 9, standard treatment = 12). There was no statistically significant difference between patient scar assessment scale and observer scar assessment scale at 4 and 8 weeks postoperatively.Despite Leptospermum Honey's reported anti-inflammatory and antibacterial properties, this study did not show a difference in scar appearance when applied.

    View details for PubMedID 29204567

    View details for PubMedCentralID PMC5698533

  • Experience With Aflibercept for the Treatment of Neovascular Age-Related Macular Degeneration. Ophthalmic surgery, lasers & imaging retina He, L., Silva, R. A., Ayoub, N., Moshfeghi, D. M., Leng, T. 2015; 46 (5): 542-549

    View details for DOI 10.3928/23258160-20150521-05

    View details for PubMedID 26057757

  • Experience With Aflibercept for the Treatment of Neovascular Age-Related Macular Degeneration. Ophthalmic surgery, lasers & imaging retina He, L., Silva, R. A., Ayoub, N., Moshfeghi, D. M., Leng, T. 2015; 46 (5): 542-549


    Describe visual and anatomic outcomes of eyes with exudative age- related macular degeneration (AMD) after treatment with aflibercept.Eyes treated with intravitreal injections of aflibercept for exudative AMD were retrospectively reviewed to compare visual acuity and central subfield thickness (CST) on optical coherence tomography.A total of 142 eyes receiving aflibercept were previously treated with bevacizumab or ranibizumab intravitreal injections. Baseline vision was 20/73 ± 5.18 lines when switched to aflibercept. It improved by 0.2 ± 1.91 lines (P =.14) after three injections but decreased by 0.45 ± 2.9 lines (P = .06) after 1 year of follow-up. The reduction in CST was 9.9 ± 46.5 µm (P = .06) after three injections and grew to 19.3 ± 50.6 µm (P = .002), a statistically significant amount, after 1 year.Switching to aflibercept resulted in no clinically significant differences in visual acuity after 1 year. There was a significant reduction in CST, but this may not be clinically significant.

    View details for DOI 10.3928/23258160-20150521-05

    View details for PubMedID 26057757