Bio


Dr. Hwang completed his undergraduate degree at Stanford University, and his MD and otolaryngology residency at the University of California, San Francisco. After completing a fellowship in rhinology at the University of Pennsylvania, Dr. Hwang served as Director of Rhinology at Oregon Health & Science University. He returned to Stanford in 2005 to lead the Division of Rhinology and Endoscopic Skull Base Surgery and currently serves as Vice Chair of Clinical Affairs for the Department of Otolaryngology-Head & Neck Surgery. Dr. Hwang has served in leadership of the American Rhinologic Society for over a decade, most recently as President of the society. Dr. Hwang also serves as Associate Editor of the International Forum of Allergy and Rhinology and Associate Editor of the World Journal of Otolaryngology. He co-edited the textbook "Rhinology: Diseases of the Nose, Sinuses, & Skull Base," which was awarded the Benjamin Franklin Award for Scientific & Technical Book of the Year. Dr. Hwang teaches on the latest advances in endoscopic sinus and skull base surgery at many national and international venues. He also trains future academic leaders in rhinology through the Stanford fellowship in rhinology and endoscopic skull base surgery. His research interests include clinical outcomes of endoscopic skull base surgery; development of innovative medical devices for treating sinus disease; and novel topical therapies for chronic rhinosinusitis.

Clinical Focus


  • Cancer > Head and Neck Cancer
  • Endoscopic Sinus Surgery
  • Endoscopic Skull Base Surgery
  • Otolaryngology
  • Otolaryngology - Head & Neck Surgery (Ear, Nose and Throat)

Academic Appointments


  • Professor - University Medical Line, Otolaryngology (Head and Neck Surgery)
  • Professor - University Medical Line (By courtesy), Neurosurgery

Administrative Appointments


  • Vice Chair, Department of Otolaryngology-Head & Neck Surgery (2018 - Present)
  • Vice Chair of Clinical Affairs, Department of Otolaryngology-Head & Neck Surgery (2015 - 2018)
  • Chief, Division of Rhinology & Endoscopic Skull Base Surgery, Stanford School of Medicine (2005 - Present)
  • Co-Director, Fellowship in Rhinology & Endoscopic Skull Base Surgery, Stanford University (2005 - 2015)

Boards, Advisory Committees, Professional Organizations


  • President, American Rhinologic Society (2015 - 2016)
  • President-Elect, American Rhinologic Society (2014 - 2015)
  • Associate Editor, World Journal of Otolaryngology-Head & Neck Surgery (2015 - Present)
  • 1st Vice President, American Rhinologic Society (2013 - 2014)
  • Associate Editor, International Forum of Allergy & Rhinology (2011 - Present)

Professional Education


  • Residency: UCSF Dept of Otolaryngology Head and Neck Surgery (1996) CA
  • Fellowship: University of Pennsylvania Dept of GME (1997) PA
  • Internship: UCSF General Surgery Residency (1992) CA
  • Medical Education: University of California at San Francisco School of Medicine (1991) CA
  • Board Certification: American Board of Otolaryngology, Otolaryngology (1997)
  • Fellowship, Univ. of Pennsylvania, Rhinology & Sinus Surgery (1997)
  • Residency, UC San Francisco, Otolaryngology (1996)
  • MD, UC San Francisco (1991)
  • BS, Stanford University, Biology (1987)

Current Research and Scholarly Interests


- Clinical outcomes in patients with chronic rhinosinusitis undergoing endoscopic sinus surgery
- Development of innovative medical devices for treatment of sinus disorders
- Founder of CORSICA, a national research registry for sinus cancer

Clinical Trials


  • Chemotherapy Before Surgery and Radiation Therapy or Surgery and Radiation Therapy Alone in Treating Patients With Nasal and Paranasal Sinus Cancer That Can Be Removed by Surgery Recruiting

    This randomized phase II trial studies how well chemotherapy before surgery and radiation therapy works compared to surgery and radiation therapy alone in treating patients with nasal and paranasal sinus cancer that can be removed by surgery. Drugs used in chemotherapy, such as docetaxel, cisplatin, and carboplatin work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Radiation therapy uses high-energy x-rays to kill tumor cells and shrink tumors. Giving chemotherapy before surgery and radiation therapy may make the tumor smaller and reduce the amount of normal tissue that needs to be removed and treated with radiation.

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  • Identification and Characterization of Novel Proteins and Genes in Head and Neck Cancer Recruiting

    Through this study, we hope to learn more about the mechanisms, which may contribute to development and progression of head and neck cancer. The long-term goal of this study will be to develop new strategies and drugs for the diagnosis and treatment of head and neck cancer.

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2024-25 Courses


Stanford Advisees


All Publications


  • A response to Min et al. International forum of allergy & rhinology Grimm, D. R., Qian, Z. J., Yong, M., Hwang, P. H. 2024

    View details for DOI 10.1002/alr.23446

    View details for PubMedID 39222268

  • Comparative analysis of traditional machine learning and automated machine learning: advancing inverted papilloma versus associated squamous cell carcinoma diagnosis. International forum of allergy & rhinology Hosseinzadeh, F., Mohammadi, S. S., Palmer, J. N., Kohanski, M. A., Adappa, N. D., Chang, M. T., Hwang, P. H., Nayak, J. V., Patel, Z. M. 2024

    Abstract

    KEY POINTS: Inverted papilloma conversion to squamous cell carcinoma is not always easy to predict. AutoML requires much less technical knowledge and skill to use than traditional ML. AutoML surpassed the traditional ML algorithm in differentiating IP from IP-SCC.

    View details for DOI 10.1002/alr.23438

    View details for PubMedID 39186252

  • Impact of sociodemographic status and sex on chronic rhinosinusitis and olfaction in people with cystic fibrosis. International forum of allergy & rhinology Han, E. J., Liu, C. M., Fischer, J. L., Mace, J. C., Markarian, K., Alt, J. A., Bodner, T. E., Chowdhury, N. I., Eshaghian, P. H., Gao, Y. A., Getz, A. E., Hwang, P. H., Khanwalkar, A., Kimple, A. J., Lee, J. T., Li, D. A., Norris, M., Nayak, J. V., Owens, C., Patel, Z. M., Poch, K., Schlosser, R. J., Smith, K. A., Smith, T. L., Soler, Z. M., Suh, J. D., Turner, G. A., Wang, M. B., Taylor-Cousar, J. L., Saavedra, M. T., Beswick, D. M. 2024

    Abstract

    Sociodemographic status (SDS) including race/ethnicity and socioeconomic status as approximated by education, income, and insurance status impact pulmonary disease in people with cystic fibrosis (PwCF). The relationship between SDS and chronic rhinosinusitis (CRS) remains understudied.In a prospective, multi-institutional study, adult PwCF completed the 22-Question SinoNasal Outcome Test (SNOT-22), Smell Identification Test (SIT), Questionnaire of Olfactory Disorder Negative Statements (QOD-NS), and Cystic Fibrosis Questionnaire-Revised (CFQ-R). Lund-Kennedy scores, sinus computed tomography, and clinical data were collected. Data were analyzed across race/ethnicity, sex, and socioeconomic factors using multivariate regression.Seventy-three PwCF participated with a mean age of 34.7 ± 10.9 years and 49 (67.1%) were female. Linear regression identified that elexacaftor/tezacaftor/ivacaftor (ETI) use (β = ‒4.09, 95% confidence interval [CI] [‒6.08, ‒2.11], p < 0.001), female sex (β = ‒2.14, 95% CI [‒4.11, ‒0.17], p = 0.034), and increasing age (β = ‒0.14, 95% CI [‒0.22, ‒0.05], p = 0.003) were associated with lower/better endoscopy scores. Private health insurance (β = 17.76, 95% CI [5.20, 30.32], p = 0.006) and >16 educational years (β = 13.50, 95% CI [2.21, 24.80], p = 0.020) were associated with higher baseline percent predicted forced expiratory volume in one second (ppFEV1). Medicaid/Medicare insurance was associated with worse endoscopy scores, CFQ-R respiratory scores, and ppFEV1 (all p < 0.017), and Hispanic/Latino ethnicity was associated with worse SNOT-22 scores (p = 0.047), prior to adjustment for other cofactors. No other SDS factors were associated with SNOT-22, QOD-NS, or SIT scores.Differences in objective measures of CRS severity exist among PwCF related to sex, age, and ETI use. Variant status and race did not influence patient-reported CRS severity measures or olfaction in this study. Understanding how these factors impact response to treatment may improve care disparities among PwCF.NCT04469439.

    View details for DOI 10.1002/alr.23402

    View details for PubMedID 38967583

  • University of Washington Quality of Life subdomain outcomes after treatment of sinonasal malignancy: A prospective, multicenter study. International forum of allergy & rhinology Maoz, S. L., Golzar, A., Choby, G., Hwang, P. H., Wang, E. W., Kuan, E. C., Adappa, N. D., Geltzeiler, M., Getz, A. E., Humphreys, I. M., Le, C. H., Pinheiro-Neto, C. D., Fischer, J. L., Chan, E. P., Abuzeid, W. M., Chang, E. H., Jafari, A., Kingdom, T. T., Kohanski, M. A., Lee, J. K., Lazor, J. W., Nabavizadeh, A., Nayak, J. V., Palmer, J. N., Patel, Z. M., Resnick, A. C., Smith, T. L., Snyderman, C. H., St John, M. A., Storm, P. B., Suh, J. D., Wang, M. B., Sim, M. S., Beswick, D. M. 2024

    Abstract

    Sinonasal malignancies (SNMs) adversely impact patients' quality of life (QOL) and are frequently identified at an advanced stage. Because these tumors are rare, there are few studies that examine the specific QOL areas that are impacted. This knowledge would help improve the care of these patients.In this prospective, multi-institutional study, 273 patients with SNMs who underwent definitive treatment with curative intent were evaluated. We used the University of Washington Quality of Life (UWQOL) instrument over 5 years from diagnosis to identify demographic, treatment, and disease-related factors that influence each of the 12 UWQOL subdomains from baseline to 5 -years post-treatment.Multivariate models found endoscopic resection predicted improved pain (vs. nonsurgical treatment CI 2.4, 19.4, p = 0.01) and appearance versus open (CI 27.0, 35.0, p < 0.001) or combined (CI 10.4, 17.1, p < 0.001). Pterygopalatine fossa involvement predicted worse swallow (CI -10.8, -2.4, p = 0.01) and pain (CI -17.0, -4.0, p < 0.001). Neck dissection predicted worse swallow (CI -14.8, -2.8, p < 0.001), taste (CI -31.7, -1.5, p = 0.02), and salivary symptoms (CI -28.4, -8.6, p < 0.001). Maxillary involvement predicted worse chewing (CI 9.8, 33.2; p < 0.001) and speech (CI -21.8, -5.4, p < 0.001) relative to other sites. Advanced T stage predicted worse anxiety (CI -13.0, -2.0, p = 0.03).Surgical approach, management of cervical disease, tumor extent, and site of involvement impacted variable UWQOL symptom areas. Endoscopic resection predicted better pain, appearance, and chewing compared with open. These results may aid in counseling patients regarding potential QOL expectations in their SNM treatment and recovery course.

    View details for DOI 10.1002/alr.23386

    View details for PubMedID 38884276

  • The Utility of a "Second-Look" Debridement Following Endonasal Skull Base Surgery in the Pediatric Population. Journal of neurological surgery. Part B, Skull base Chang, M. T., Huang, A. E., Quon, J. L., Fernandez-Miranda, J. C., Wen, C. Z., Eide, J. G., Kshirsagar, R. S., Qian, Z. J., Nayak, J. V., Hwang, P. H., Adappa, N. D., Patel, Z. M. 2024; 85 (3): 313-317

    Abstract

    Background  Sinonasal debridement is typically performed in the weeks following endonasal skull base surgery (ESBS). In the pediatric population, this second-look procedure may require general anesthesia; however, there is currently little evidence assessing the benefit of this practice. Methods  This was a multicenter retrospective study of pediatric patients (age <18 years) undergoing a planned second-look debridement under general anesthesia following ESBS. Intraoperative findings, interventions performed, and perioperative complications were reviewed. Multivariate regression analysis was performed to identify associations between intraoperative findings and clinical factors. Results  We reviewed 69 cases of second-look debridements (age mean 8.6 ± 4.2 years, range: 2-18 years), occurring a mean of 18.3 ± 10.3 days following ESBS. All abnormal findings were noted in patients age ≤12 years. Synechiae were noted in 8.7% of cases, bacterial rhinosinusitis in 2.9%, and failed reconstruction with cerebrospinal fluid leak in 4.5% (two cases of flap malposition and one case of flap necrosis). All failed reconstructions were noted following expanded endonasal cases for craniopharyngioma, and in each case, a revision reconstruction was performed during the second-look surgery. Synechiae were not significantly associated with younger age, revision cases, or cases with reconstructive flaps. There were no perioperative complications. Conclusion  Second-look debridement under general anesthesia may be useful in the identification and intervention of sinonasal pathology following endoscopic skull base surgery, particularly in children ≤12 years old or those with pedicled flap reconstructions. Larger controlled studies are warranted to validate this practice and refine indications and timing of this second procedure.

    View details for DOI 10.1055/a-2048-7564

    View details for PubMedID 38721369

    View details for PubMedCentralID PMC11076083

  • Predictors of Sinonasal Improvement After Highly Effective Modulator Therapy in Adults with Cystic Fibrosis. The Laryngoscope Beswick, D. M., Liu, C. M., Overdevest, J. B., Zemke, A., Khatiwada, A., Gudis, D. A., Miller, J. E., Kimple, A., Tervo, J. P., DiMango, E., Goralski, J. L., Keating, C., Senior, B., Stapleton, A. L., Eshaghian, P. H., Mace, J. C., Markarian, K., Alt, J. A., Bodner, T. E., Chowdhury, N. I., Getz, A. E., Hwang, P. H., Khanwalker, A., Lee, J. T., Li, D. A., Norris, M., Nayak, J. V., Owens, C., Patel, Z. M., Poch, K., Schlosser, R. J., Smith, K. A., Smith, T. L., Soler, Z. M., Suh, J. D., Turner, G. A., Wang, M. B., Saavedra, M. T., Taylor Cousar, J. L. 2024

    Abstract

    OBJECTIVES: The 22-question SinoNasal Outcome Test (SNOT-22) assesses chronic rhinosinusitis (CRS) severity. We aimed to identify predictors of SNOT-22 score improvement following highly effective modulator therapy (HEMT) initiation and to corroborate the SNOT-22 minimal clinically important difference (MCID) in adults with cystic fibrosis (CF).METHODS: Prospective observational data was pooled from four studies across 10US centers investigating people with CF (PwCF) and CRS. Three studies evaluated HEMT's impact on CRS. For participants enrolled prior to HEMT initiation, SNOT-22 scores were obtained at baseline and after 3-6months of HEMT. Multivariate regression identified predictors of improvement. Cronbach's alpha and four distribution-based methods were used to assess internal consistency and calculate the MCID of the SNOT-22.RESULTS: A total of 184 PwCF participated with mean baseline SNOT-22 scores ranging from 18.1 to 56.7. Cronbach's alpha was ≥0.90 across sites. Participants at sites with pre- and post-HEMT data reported improvement in SNOT-22 scores after initiating HEMT (all p<0.05). Worse baseline SNOT-22 score (odds ratio (OR): 1.05, p<0.001, 95% CI: 1.02-1.08), F508del homozygosity (OR: 4.30, p=0.040, 95% CI: 1.14-18.99), and absence of prior modulator therapy (OR: 4.99, p=0.017, 95% CI: 1.39-20.11) were associated with greater SNOT-22 improvement. The mean MCID calculated via distribution-based methods was 8.5.CONCLUSION: Worse baseline sinonasal symptoms, F508del homozygosity, and absence of prior modulator therapy predicted greater improvement after HEMT initiation. The mean MCID for SNOT-22 in PwCF is 8.5 points, similar to non-CF individuals with CRS, and provides a threshold specifically for PwCF. The SNOT-22 has strong internal consistency in PwCF.LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

    View details for DOI 10.1002/lary.31438

    View details for PubMedID 38634358

  • Recurrence morbidity of olfactory neuroblastoma. International forum of allergy & rhinology Melder, K., Mace, J. C., Choby, G., Almeida, J. P., Champagne, P., Chan, E., Ciporen, J., Chaskes, M. B., Fernandez-Miranda, J., Fung, N. K., Gardner, P., Hwang, P., Ji, K. S., Kalyvas, A., Kong, K. A., Patel, C., Patel, Z., Celda, M. P., Pinheiro-Neto, C. D., Snyderman, C., Thorp, B. D., Van Gompel, J. J., Zenonos, G., Zwagerman, N. T., Sanusi, O., Wang, E. W., Geltzeiler, M. 2024

    Abstract

    BACKGROUND: With modern treatment paradigms, olfactory neuroblastoma (ONB) has favorable overall survival (OS); however, the incidence of recurrence remains high. The primary aims of this study were to delineate the prognosis of recurrence of ONB and explore how recurrence subsites are associated with OS, disease-specific survival (DSS), and further recurrence.METHODS: A retrospective chart review of ONB cases from nine academic centers between 2005 and 2021 was completed. Tumor characteristics, recurrence subsites, timelines to recurrence, additional recurrences, and survival estimates were determined using descriptive and time-to-event analyses.RESULTS: A final cohort of 233 patients was identified, with 70 (30.0%) patients recurring within 50.4 (standard deviation±40.9) months of diagnosis on average, consisting of local (50%), neck (36%), intracranial (9%), and distant (6%) recurrence. Compared with subjects without recurrence, patients with recurrence had significantly different primary American Joint Committee on Cancer T stage (p<0.001), overall stage (p<0.001), and modified Kadish scores (p<0.001). Histopathology identified that dural involvement and positive margins were significantly greater in recurrent cases. First recurrence was significantly associated with worse 5-year DSS (hazard ratio=5.62; p=0.003), and subjects with neck or local recurrence had a significantly better DSS compared to intracranial or distant recurrence.CONCLUSIONS: Recurrent cases of ONB have significantly different stages and preoperative imaging factors. Patients with local or neck recurrence, however, have better DSS than those with intracranial or distant recurrence, independent of initial tumor stage or Hyams grade. Identifying specific factors that confer an increased risk of recurrence and DSS is important for patient counseling in addition to surveillance planning.

    View details for DOI 10.1002/alr.23351

    View details for PubMedID 38567900

  • The effect of PM2.5 on acute sinusitis: A population-based study. International forum of allergy & rhinology Grimm, D., Qian, Z. J., Yong, M., Hwang, P. H. 2024

    Abstract

    PM2.5 exposure is a risk factor for the development of acute sinusitis. PM2.5 exposure affects acute sinusitis in a dose response fashion.

    View details for DOI 10.1002/alr.23328

    View details for PubMedID 38400591

  • SNOT-22 subdomain outcomes following treatment for sinonasal malignancy: A prospective, multicenter study. International forum of allergy & rhinology Grimm, D. R., Beswick, D. M., Maoz, S. L., Wang, E. W., Choby, G. W., Kuan, E. C., Chan, E. P., Adappa, N. D., Geltzeiler, M., Getz, A. E., Humphreys, I. M., Le, C. H., Abuzeid, W. M., Chang, E. H., Jafari, A., Kingdom, T. T., Kohanski, M. A., Lee, J. K., Nayak, J. V., Palmer, J. N., Patel, Z. M., Pinheiro-Neto, C. D., Resnick, A. C., Sim, M. S., Smith, T. L., Snyderman, C. H., John, M. A., Storm, P., Suh, J. D., Wang, M. B., Hwang, P. H. 2024

    Abstract

    Patients with sinonasal malignancy (SNM) present with significant sinonasal quality of life (QOL) impairment. Global sinonasal QOL as measured by the 22-item Sinonasal Outcomes Test (SNOT-22) has been shown to improve with treatment. This study aims to characterize SNOT-22 subdomain outcomes in SNM.Patients diagnosed with SNM were prospectively enrolled in a multi-center patient registry. SNOT-22 scores were collected at the time of diagnosis and through the post-treatment period for up to 5 years. Multivariable regression analysis was used to identify drivers of variation in SNOT-22 subdomains.Note that 234 patients were reviewed, with a mean follow-up of 22 months (3 months-64 months). Rhinologic, psychological, and sleep subdomains significantly improved versus baseline (all p < 0.05). Subanalysis of 40 patients with follow-up at all timepoints showed statistically significant improvement in rhinologic, extra-nasal, psychological, and sleep subdomains, with minimal clinically important difference met between 2 and 5 years in sleep and psychological subdomains. Adjuvant chemoradiation was associated with worse outcomes in rhinologic (adjusted odds ratio (5.22 [1.69-8.66])), extra-nasal (2.21 [0.22-4.17]) and ear/facial (5.53 [2.10-8.91]) subdomains. Pterygopalatine fossa involvement was associated with worse outcomes in rhinologic (3.22 [0.54-5.93]) and ear/facial (2.97 [0.32-5.65]) subdomains. Positive margins (5.74 [2.17-9.29]) and surgical approach-combined versus endoscopic (3.41 [0.78-6.05])-were associated with worse psychological outcomes. Adjuvant radiation (2.28 [0.18-4.40]) was associated with worse sleep outcomes.Sinonasal QOL improvements associated with treatment of SNM are driven by rhinologic, extra-nasal, psychological, and sleep subdomains.

    View details for DOI 10.1002/alr.23338

    View details for PubMedID 38372441

  • Patient perspectives on chronic rhinosinusitis in cystic fibrosis: Symptom prioritization in the era of highly effective modulator therapy. International forum of allergy & rhinology Liu, C. M., Han, E. J., Fischer, J. L., Mace, J. C., Mattos, J. L., Markarian, K., Alt, J. A., Bodner, T. E., Chowdhury, N. I., Eshaghian, P. H., Getz, A. E., Hwang, P. H., Khanwalkar, A., Kimple, A. J., Lee, J. T., Li, D. A., Norris, M., Nayak, J. V., Owens, C., Patel, Z. M., Poch, K., Schlosser, R. J., Smith, K. A., Smith, T. L., Soler, Z. M., Suh, J. D., Turner, G. A., Wang, M. B., Taylor-Cousar, J. L., Saavedra, M. T., Beswick, D. M. 2024

    Abstract

    Chronic rhinosinusitis (CRS) is common in people with cystic fibrosis (PwCF). Rhinologic symptom prioritization and areas that influence CRS treatment choices, including pursuing endoscopic sinus surgery (ESS), remain understudied.Adult PwCF + CRS were enrolled at eight centers into a prospective, observational study (2019-2023). Participants were administered the 22-SinoNasal Outcome Test (SNOT-22) survey and a modified SNOT-22 instrument examining symptom importance. We determined importance rankings for individual symptoms and SNOT-22 symptom importance subdomains in two sets of subgroups-those pursuing ESS versus continuing medical management (CMT), and those on elexacaftor/tezacaftor/ivacaftor (ETI) versus not on ETI.Among 69 participants, the highest priorities were nasal congestion (n = 48, 69.6% important), post-nasal discharge (32, 46.4%), facial pain (29, 43.3%), waking up tired (27, 39.1%), and fatigue (26, 37.7%). Those electing surgery (n = 23) prioritized sleep and psychological dysfunction symptoms compared to those pursuing CMT (n = 49) (sleep median score = 19.0 [interquartile range: 12.0, 25.0] vs. 4.5 [0.0, 12.8]; p < 0.0001; psychological = 17.0 [7.0, 26.0] vs. 7.0 [0.0, 15.8]; p = 0.002). ETI users had comparable SNOT-22 total symptom importance scores to non-ETI users (p = 0.14). Non-ETI users (n = 34) showed a trend toward prioritizing sleep symptoms compared to ETI users (n = 35) (13.0 [2.8, 22.3] vs. 6.0 [2.0, 17.0]; p = 0.055).Nasal congestion and post-nasal discharge were top priorities reported by PwCF + CRS. Those electing surgery prioritized sleep and psychological symptoms, highlighting their importance in pre-operative discussions. Non-ETI users' prioritization of sleep improvement may highlight their unique disease impact and therapeutic needs; however, additional investigation is required.

    View details for DOI 10.1002/alr.23332

    View details for PubMedID 38343143

  • Impact of dupilumab prescribing on utilization of medical and surgical therapies for chronic rhinosinusitis with nasal polyps. International forum of allergy & rhinology Low, C. M., Wang, A. R., Yong, M., Nayak, J., Patel, Z., Hwang, P. H. 2024

    Abstract

    Increased dupilumab utilization coincided with decreased ESS in patients with CRSwNP between 2019 and 2021. One potential confounder was the concurrent COVID-19 pandemic, which may have negatively impacted surgery utilization rates.

    View details for DOI 10.1002/alr.23325

    View details for PubMedID 38297486

  • Ipsilateral Nasoseptal Flaps in a Transpterygoid Approach: Technical Pearls and Reconstruction Outcomes JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Chang, M. T., Grimm, D., Asmaro, K., Yong, M., Low, C., Lee, C. K., Nayak, J. V., Hwang, P. H., Fernandez-Miranda, J. C., Patel, Z. M. 2024
  • Impact of sinus surgery in people with cystic fibrosis and chronic rhinosinusitis in the era of highly effective modulator therapy: Protocol for a prospective observational study. PloS one Liu, C. M., Fischer, J. L., Alt, J. A., Bodner, T. E., Chowdhury, N. I., Getz, A. E., Hwang, P. H., Kimple, A. J., Mace, J. C., Smith, T. L., Soler, Z. M., Goss, C. H., Taylor-Cousar, J. L., Saavedra, M. T., Beswick, D. M. 2024; 19 (9): e0310986

    Abstract

    INTRODUCTION: Cystic fibrosis (CF) is commonly complicated by chronic rhinosinusitis (CRS). Despite highly effective management options, CRS in people with CF (PwCF+CRS) may be refractory to medical therapy, eventually requiring endoscopic sinus surgery. The impact of sinus surgery on pulmonary, quality of life (QOL), and other outcomes in PwCF+CRS in the expanding era of highly effective modulator therapy has not been fully elucidated. This study aims to determine if endoscopic sinus surgery can offer superior outcomes for PwCF+CRS when compared to continued medical treatment of CRS.METHODS AND ANALYSIS: This multi-institutional, observational, prospective cohort study will enroll 150 adults with PwCF+CRS across nine US CF Centers who failed initial medical therapy for CRS and elected to pursue either endoscopic sinus surgery or continue medical treatment. To determine if sinus surgery outperforms continued medical therapy in different outcomes, we will assess changes in pulmonary, CF-specific QOL, CRS-specific QOL, sleep quality, depression, headache, cognition, olfaction, productivity loss, and health utility value after treatment. The influence of highly effective modulator therapy on these outcomes will also be evaluated. This study will provide crucial insights into the impact of endoscopic sinus surgery for PwCF+CRS and aid with development of future treatment pathways and guidelines.ETHICS AND DISSEMINATION: This study has been approved by each institution's internal review board, and study enrollment began August 2019. Results will be disseminated in conferences and peer-reviewed journals.TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov (NCT04469439).

    View details for DOI 10.1371/journal.pone.0310986

    View details for PubMedID 39325787

  • In Response to Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis. The Laryngoscope Yong, M., Aravinthan, K., Kirubalingam, K., Thamboo, A., Hwang, P. H., Nadeau, K., Walgama, E. 2023

    View details for DOI 10.1002/lary.31247

    View details for PubMedID 38153190

  • Determining the minimal clinically important difference for the questionnaire of olfactory disorders in people with cystic fibrosis and factors associated with improvement after highly effective modulator therapy. International forum of allergy & rhinology Miller, J. E., Taylor-Cousar, J. L., Overdevest, J. B., Khatiwada, A., Mace, J. C., Alt, J. A., Bodner, T. E., Chowdhury, N. I., DiMango, E. A., Eshaghian, P. H., Getz, A. E., Gudis, D. A., Han, E. J., Hwang, P. H., Keating, C. L., Khanwalkar, A., Kimple, A. J., Lee, J. T., Li, D., Markarian, K., Norris, M., Nayak, J. V., Owens, C., Patel, Z. M., Poch, K., Schlosser, R. J., Smith, K. A., Smith, T. L., Soler, Z. M., Suh, J. D., Tervo, J. P., Turner, G. A., Wang, M. B., Saavedra, M. T., Beswick, D. M. 2023

    Abstract

    INTRODUCTION: Olfactory dysfunction (OD) is common among people with cystic fibrosis (PwCF). The Questionnaire of Olfactory Disorders (QOD) is a validated instrument that evaluates olfactory-specific quality-of-life. The QOD minimal clinically important difference (MCID) and factors associated with olfactory improvement after elexacaftor/tezacaftor/ivacaftor have not been determined for PwCF.METHODS: Prospective observational data were pooled from three studies that enrolled adult PwCF with chronic rhinosinusitis (CRS). QOD scores and disease characteristics were assessed. To evaluate internal consistency and calculate the QOD MCID, Cronbach's alpha and four distribution-based methods were employed. For participants who enrolled prior to elexacaftor/tezacaftor/ivacaftor, QOD scores were obtained at baseline and after elexacaftor/tezacaftor/ivacaftor initiation. Multivariable regression was used to identify factors associated with QOD improvement.RESULTS: Of 129 PwCF included, 65 had QOD scores before and 3-6 months after starting elexacaftor/tezacaftor/ivacaftor. Mean baseline QOD score was 6.5±7.9. Mean Cronbach's alpha was ≥0.85. The MCID estimates were as follows: Cohen's effect size=1.6, standard error of measurement=2.5, baseline standard deviation=4.0, and minimal detectable change=6.9. Mean MCID was 3.7. Of those with pre/post elexacaftor/tezacaftor/ivacaftor QOD scores, the mean change in QOD was -1.3±5.4. After elexacaftor/tezacaftor/ivacaftor, QOD improvement surpassed the MCID in 22% of participants (14/65). Worse baseline QOD scores and nasal polyps were associated with improved QOD scores after elexacaftor/tezacaftor/ivacaftor (both p<0.04).CONCLUSION: The QOD MCID in PwCF was estimated to be 3.7. Elexacaftor/tezacaftor/ivacaftor led to qualitative but not clinically meaningful improvements in QOD score for most PwCF; PwCF with worse baseline QOD scores and nasal polyps improved in a clinically significant manner.

    View details for DOI 10.1002/alr.23312

    View details for PubMedID 38145393

  • Impact of functional endoscopic sinonasal surgery on oral corticosteroid burden and healthcare resource utilization in patients with chronic rhinosinusitis with nasal polyps in US real-world practice Isaman, D., Khan, A., Lee, S., Peters, A., Hwang, P., Reitsma, S., Petruski-Ivleva, N., Nash, S., Jacob-Nara, J. A. WILEY. 2023: 110
  • Characteristics of patients with chronic rhinosinusitis with nasal polyps who did or did not undergo functional endoscopic sinus surgery: A US real-world retrospective cohort study Khan, A., Isaman, D., Lee, S., Peters, A., Hwang, P., Reitsma, S., Petruski-Ivleva, N., Nash, S., Jacob-Nara, J. A. WILEY. 2023: 109
  • Surgical Correction of Nasal Obstruction and Its Effect on Eustachian Tube Dysfunction Symptoms. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Daum, R., Grimm, D., Castro Silva, B. R., Huang, A. E., Lee, J. Y., Nayak, J. V., Patel, Z. M., Hwang, P. H., Chang, M. T. 2023

    Abstract

    To investigate how eustachian tube dysfunction symptoms change following surgical treatment of nonsinusitis-related nasal obstruction.Retrospective chart review.Single academic center.We assessed patients who underwent septoplasty, turbinate reduction, or both for nasal obstruction. Chronic sinusitis patients were excluded. Eustachian tube dysfunction (ETD) symptoms were studied using the Eustachian Tube Dysfunction Questionnaire (ETDQ-7), collected preoperatively and postoperatively (1 week, 1 month, 3 months, 6 months postop). Patients with preoperative ETDQ-7 > 14.5 were considered to have clinically significant symptoms. Sinonasal outcomes test scores were also assessed. Pre- and postoperative ETDQ-7 scores were compared using t test. Multivariate linear regression analysis identified factors associated with ETDQ-7 change.We analyzed 259 patients. Preoperatively, 37.5% of patients with nasal obstruction had clinically significant ETD symptoms. These patients exhibited significant improvement in ETDQ-7 at all postoperative timepoints from 23.3 ± 7.6 at baseline to 19.1 ± 9.1 at 1 week, 16.5 ± 8.0 at 1 month, 16.2 ± 7.8 at 3 months, and 16.7 ± 10.4 at 6 months (all P < .01). In patients without baseline ETD symptoms, (baseline ETDQ-7: 9.1 ± 2.3) ETDQ-7 scores did not change significantly at postoperative timepoints, except for an acute worsening at 1 week postoperatively (10.7 ± 5.1, P < .001). Regression analysis showed that higher preoperative ETDQ-7 score (β = -0.84, 95% confidence interval [CI]: -1.10 to -0.59) and postoperative antihistamine spray usage (β = -8.70, 95% CI: -14.20 to -3.20) were associated with ETDQ-7 improvement, while comorbid GERD (β = 7.50, 95% CI: 3.42-11.58) and asthma (β = 5.62, 95% CI: 0.80-10.45) were negatively associated with improvement.Surgical correction of nasal obstruction may improve ETD symptoms.

    View details for DOI 10.1002/ohn.607

    View details for PubMedID 38037398

  • Acoustic resonance therapy is safe and effective for the treatment of nasal congestion in rhinitis: A randomized sham-controlled trial. International forum of allergy & rhinology Luong, A. U., Yong, M., Hwang, P. H., Lin, B. Y., Gopi, P., Mohan, V., Ma, Y., Johnson, J., Yen, D. M., DeMera, R. S., Bleier, B. S. 2023

    Abstract

    Acoustic resonance therapy (ART) is a novel vibrational treatment that delivers patient-specific resonant frequency acoustic energy to the sinonasal cavities. In a pilot study, ART was effective for the acute treatment of nasal congestion. We conducted a sham-controlled randomized trial to validate the efficacy of ART when administered daily for 2 weeks.A total of 52 adult patients were enrolled in a multi-center, randomized, double-blinded, sham-controlled, interventional study evaluating ART administered by a vibrational headband. Patients received either active treatment or a non-therapeutic sham treatment twice daily over 2 weeks. Clinical endpoints were the average change in nasal congestion sub-score of the Total Nasal Symptom Score (TNSS) and the average change in composite TNSS.ART resulted in a significantly greater mean change in the nasal congestion sub-score compared to sham (-0.87 [95% confidence interval [CI] -1.11, -0.62] vs. -0.44 [95% CI -0.64, -0.23], p = 0.008). ART also resulted in a significantly greater reduction in the composite TNSS versus sham, (-2.85 [95% CI -3.85, -1.85], vs. -1.32 [95% CI -2.27, -0.36], p = 0.027). The response rate, determined by a nasal congestion sub-score minimal clinically important difference of 0.23, was 80.8% for ART and 46.2% for sham, with an adjusted risk ratio of 1.95 (95% CI 1.26, 3.02, p = 0.003) in favor of ART. Safety endpoints showed no adverse events.ART is a safe and effective non-pharmacologic alternative for the treatment of nasal congestion.

    View details for DOI 10.1002/alr.23284

    View details for PubMedID 37812532

  • Chronic Rhinosinusitis After Maxillary Advancement Orthognathic Surgery. The Annals of otology, rhinology, and laryngology Ibrahim, N., Hwang, P. H., Jitaroon, K., Tyler, M. A. 2023: 34894231204654

    Abstract

    INTRODUCTION: Maxillomandibular advancement (MMA) remains an effective procedure for the management of obstructive sleep apnea (OSA). Maxillary advancement may lead to anatomical changes that impair paranasal sinus drainage, leading to chronic sinus inflammation. The aim of this study was to describe the clinical features and outcomes of patients suffering from chronic rhinosinusitis (CRS) following MMA.METHODS: This is a retrospective case series study. Our study included subjects diagnosed with CRS following MMA from January 1992 to October 2018 at Stanford Hospital. We screened 730 patients undergoing MMA and identified a total of 57 with CRS after MMA. A descriptive analysis was performed using clinical data including patient demographics, comorbidities, prior surgical history, physical exam manifestations, CT findings, and quality of life outcomes (SNOT-22).RESULTS: Out of 730 patients undergoing MMA, 57(7.8%) were found to have CRS after orthognathic surgery. Presenting symptoms included facial pain (92.5%), nasal drainage (75%), nasal obstruction (67.5%), and hyposmia (20%). Endoscopic examination revealed recirculation (30.5%), purulent discharge (27.7%), polypoid changes (22.2%), and scarring (13.8%). Preoperative CT prior to undergoing endoscopic sinus surgery (ESS) demonstrated mucosal thickening in maxillary (64.2%), anterior ethmoid (39.2%), frontal (14.2%), posterior ethmoid (10.7%), sphenoid sinus (14.2%), and ostiomeatal complex (55.3%). Average Lund-Mackay score was 5.5(±3.8). Additional CT findings included secondary ostium in the inferior meatus (42.8%). Forty patients (70.1%) underwent ESS at a mean of 4.6years after MMA. Patients undergoing ESS experienced significant improvement in SNOT-22 scores at 12-months post-surgery (P=.018).CONCLUSION: Patients undergoing maxillary advancement surgery are at risk of developing CRS postoperatively and should be advised of the risk of CRS associated with this procedure. Surgical treatment can be an option for medically refractory CRS related to MMA surgery.

    View details for DOI 10.1177/00034894231204654

    View details for PubMedID 37800544

  • Factors that predict pursuing sinus surgery in the era of highly effective modulator therapy. International forum of allergy & rhinology Beswick, D. M., Han, E. J., Mace, J. C., Markarian, K., Alt, J. A., Bodner, T. E., Chowdhury, N. I., Eshaghian, P. H., Getz, A. E., Hwang, P. H., Khanwalkar, A., Kimple, A. J., Lee, J. T., Li, D. A., Norris, M., Nayak, J. V., Owens, C., Patel, Z., Poch, K., Schlosser, R. J., Smith, K. A., Smith, T. L., Soler, Z. M., Suh, J. D., Turner, G., Wang, M. B., Taylor-Cousar, J. L., Saavedra, M. 2023

    Abstract

    BACKGROUND: Comorbid chronic rhinosinusitis (CRS) remains unresolved for many people with cystic fibrosis (PwCF). While highly effective modulator therapy improves quality-of-life and symptom severity, the impact of this intervention and other factors associated with pursuing endoscopic sinus surgery (ESS) remains understudied.METHODS: Adult PwCF + CRS were enrolled into a prospective, observational, multi-institutional study. Participants completed validated outcome measures to evaluate respiratory symptom severity, depression, headache, and sleep quality, as well as nasal endoscopy, sinus computed tomography (CT), and olfactory testing. Bivariate comparisons and regression modeling evaluated treatment cofactors, disease characteristics, and outcome measures associated with pursuing ESS.RESULTS: Sixty PwCF were analyzed, including 24 (40%) who elected ESS. Pursuing ESS was associated with worse SinoNasal Outcome Test (SNOT-22) total, rhinologic, psychological, and sleep dysfunction domain scores; worse Patient Health Questionnaire-9-Revised depression scores; worse Pittsburgh Sleep Quality Index total scores; worse weight, role, emotion, and eating domain scores on the Cystic Fibrosis Questionnaire-Revised; more severe disease on nasal endoscopy; and lack of modulator therapy (all p<0.050). Multivariable regression identified that worse SNOT-22 total score was associated with electing ESS (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.02-1.16, p=0.015) and elexacaftor/tezacaftor/ivacaftor (ETI) treatment (OR 0.04, 95% CI 0.004-0.34, p=0.004) was associated with pursing medical therapy.CONCLUSIONS: Worse sinonasal symptom burden, lack of ETI treatment, sleep quality, depression, and nasal endoscopy scores were associated with electing ESS, while lung disease severity and sinus CT scores were not. ETI use was associated with lower odds of pursuing ESS independent of sinonasal symptom burden.

    View details for DOI 10.1002/alr.23270

    View details for PubMedID 37725072

  • Eustachian tube dysfunction symptoms after endonasal skull base surgery. International forum of allergy & rhinology Grimm, D., Daum, R., Castro Silva, B. R., Lee, C. K., Fernandez-Miranda, J. C., Nayak, J. V., Patel, Z. M., Hwang, P. H., Chang, M. T. 2023

    Abstract

    ETD symptoms are present in 16% patients with underlying skull base pathology. Preoperative ETD symptoms improve following surgical treatment of skull base pathology. ETD symptoms may worsen in patients with central, posterior, or malignant skull base pathology.

    View details for DOI 10.1002/alr.23266

    View details for PubMedID 37694445

  • Oral corticosteroid (OCS) burden and healthcare resource utilization (HCRU) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) who did or did not undergo functional endoscopic sinonasal surgery (FESS) in US real-world practice Khan, A. H., Isaman, D., Lee, S., Peters, A., Hwang, P., Reitsma, S., Petruski-Ivleva, N., Nash, S., Jacob-Nara, J., Jacob-Nara, J. EUROPEAN RESPIRATORY SOC JOURNALS LTD. 2023
  • International consensus statement on allergy and rhinology: Sinonasal tumors. International forum of allergy & rhinology Kuan, E. C., Wang, E. W., Adappa, N. D., Beswick, D. M., London, N. R., Su, S. Y., Wang, M. B., Abuzeid, W. M., Alexiev, B., Alt, J. A., Antognoni, P., Alonso-Basanta, M., Batra, P. S., Bhayani, M., Bell, D., Bernal-Sprekelsen, M., Betz, C. S., Blay, J. Y., Bleier, B. S., Bonilla-Velez, J., Callejas, C., Carrau, R. L., Casiano, R. R., Castelnuovo, P., Chandra, R. K., Chatzinakis, V., Chen, S. B., Chiu, A. G., Choby, G., Chowdhury, N. I., Citardi, M. J., Cohen, M. A., Dagan, R., Dalfino, G., Dallan, I., Dassi, C. S., de Almeida, J., Tos, A. P., DelGaudio, J. M., Ebert, C. S., El-Sayed, I. H., Eloy, J. A., Evans, J. J., Fang, C. H., Farrell, N. F., Ferrari, M., Fischbein, N., Folbe, A., Fokkens, W. J., Fox, M. G., Lund, V. J., Gallia, G. L., Gardner, P. A., Geltzeiler, M., Georgalas, C., Getz, A. E., Govindaraj, S., Gray, S. T., Grayson, J. W., Gross, B. A., Grube, J. G., Guo, R., Ha, P. K., Halderman, A. A., Hanna, E. Y., Harvey, R. J., Hernandez, S. C., Holtzman, A. L., Hopkins, C., Huang, Z., Huang, Z., Humphreys, I. M., Hwang, P. H., Iloreta, A. M., Ishii, M., Ivan, M. E., Jafari, A., Kennedy, D. W., Khan, M., Kimple, A. J., Kingdom, T. T., Knisely, A., Kuo, Y. J., Lal, D., Lamarre, E. D., Lan, M. Y., Le, H., Lechner, M., Lee, N. Y., Lee, J. K., Lee, V. H., Levine, C. G., Lin, J. C., Lin, D. T., Lobo, B. C., Locke, T., Luong, A. U., Magliocca, K. R., Markovic, S. N., Matnjani, G., McKean, E. L., Meço, C., Mendenhall, W. M., Michel, L., Na'ara, S., Nicolai, P., Nuss, D. W., Nyquist, G. G., Oakley, G. M., Omura, K., Orlandi, R. R., Otori, N., Papagiannopoulos, P., Patel, Z. M., Pfister, D. G., Phan, J., Psaltis, A. J., Rabinowitz, M. R., Ramanathan, M., Rimmer, R., Rosen, M. R., Sanusi, O., Sargi, Z. B., Schafhausen, P., Schlosser, R. J., Sedaghat, A. R., Senior, B. A., Shrivastava, R., Sindwani, R., Smith, T. L., Smith, K. A., Snyderman, C. H., Solares, C. A., Sreenath, S. B., Stamm, A., Stölzel, K., Sumer, B., Surda, P., Tajudeen, B. A., Thompson, L. D., Thorp, B. D., Tong, C. C., Tsang, R. K., Turner, J. H., Turri-Zanoni, M., Udager, A. M., van Zele, T., VanKoevering, K., Welch, K. C., Wise, S. K., Witterick, I. J., Won, T. B., Wong, S. N., Woodworth, B. A., Wormald, P. J., Yao, W. C., Yeh, C. F., Zhou, B., Palmer, J. N., Abiri, A., Adams, C. D., Ayoub, N. F., Bitner, B. F., Boyd, J. T., Chang, M. T., Chapurin, N., Chaskes, M. B., Chua, A., Chung, S. Y., Contrera, K. J., Dilley, K. K., Dutra, A. Z., Eide, J. G., Fenberg, R., Godse, N. R., Jawad, B., Johnson, J., Johnson, B. J., Judd, R., Khalife, S., Khosravi, P., Kolarski, M. M., Kong, K. A., Kshirsagar, R. S., Lee, J. S., Lin, T. Y., McCormick, J. P., Melder, K., Morse, E., Nguyen, T. V., Norwood, T. G., Pang, J. C., Parsel, S. M., Patel, P. S., Ringel, B., Schneider, A. L., Spielman, D. B., Spock, T., Vasudev, M. 2023

    Abstract

    Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represents a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.In accordance with prior ICAR documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.The ICNST document consists of 4 major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23262

    View details for PubMedID 37658764

  • Predictive factors for decreased baseline quality of life in patients with sinonasal malignancies. International forum of allergy & rhinology Fleseriu, C. M., Beswick, D. M., Maoz, S. L., Hwang, P. H., Choby, G., Kuan, E. C., Chan, E. P., Adappa, N. D., Geltzeiler, M., Getz, A. E., Humphries, I. M., Le, C. H., Abuzeid, W. M., Chang, E. H., Jafari, A., Kingdom, T. T., Kohanski, M. A., Lee, J. K., Nabavizadeh, S. A., Nayak, J. V., Palmer, J. N., Patel, Z. M., Pinheiro-Neto, C. D., Resnick, A. C., Smith, T. L., Snyderman, C. H., St John, M. A., Storm, J., Suh, J. D., Wang, M. B., Wang, E. W. 2023

    Abstract

    The impact of sinonasal malignancies (SNMs) on quality of life (QOL) at presentation is poorly understood. The Sinonasal Outcome Test (SNOT-22) and University of Washington Quality of Life (UWQOL) are validated QOL instruments with distinctive subdomains. This study aims to identify factors impacting pretreatment QOL in SNM patients to personalize multidisciplinary management and counseling.Patients with previously untreated SNMs were prospectively enrolled (2015-2022) in a multicenter observational study. Baseline pretreatment QOL instruments (SNOT-22, UWQOL) were obtained along with demographics, comorbidities, histopathology/staging, tumor involvement, and symptoms. Multivariable regression models identified factors associated with reduced baseline QOL.Among 204 patients, presenting baseline QOL was significantly reduced. Multivariable regression showed worse total SNOT-22 QOL in patients with skull base erosion (p = 0.02). SNOT-rhinologic QOL was worse in women (p = 0.009), patients with epistaxis (p = 0.036), and industrial exposure (p = 0.005). SNOT extranasal QOL was worse in patients with industrial exposure (p = 0.016); worse SNOT ear/facial QOL if perineural invasion (PNI) (p = 0.027). Squamous cell carcinoma pathology (p = 0.037), palate involvement (p = 0.012), and pain (p = 0.017) were associated with worse SNOT sleep QOL scores. SNOT psychological subdomain scores were significantly worse in patients with palate lesions (p = 0.022), skull base erosion (p = 0.025), and T1 staging (p = 0.023). Low QOL was more likely in the presence of PNI on UW health (p = 0.019) and orbital erosion on UW overall (p = 0.03). UW social QOL was worse if palatal involvement (p = 0.023) or PNI (p = 0.005).Our findings demonstrate a negative impact on baseline QOL in patients with SNMs and suggest sex-specific and symptom-related lower QOL scores, with minimal histopathology association. Anatomical tumor involvement may be more reflective of QOL than T-staging, as orbital and skull base erosion, PNI, and palate lesions are significantly associated with reduced baseline QOL.

    View details for DOI 10.1002/alr.23261

    View details for PubMedID 37646428

  • Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis. The Laryngoscope Yong, M., Aravinthan, K., Kirubalingam, K., Thamboo, A., Hwang, P. H., Nadeau, K., Walgama, E. 2023

    Abstract

    Allergic rhinitis (AR) is a common condition that is frequently associated with atopic inferior turbinate hypertrophy (ITH) resulting in nasal obstruction. Current guidelines support the use of subcutaneous allergen immunotherapy (SCIT) when patients fail pharmacologic management. However, there is a lack of consensus regarding the role of inferior turbinate reduction (ITR), a treatment that we hypothesize is cost-effective compared with other available treatments.We conducted a cost-effectiveness analysis comparing the following treatment combinations over a 5-year time horizon for AR patients presenting with atopic nasal obstruction who fail initial pharmacotherapy: (1) continued pharmacotherapy alone, (2) allergy testing and SCIT, (3) allergy testing and SCIT and then ITR for SCIT nonresponders, and (4) ITR and then allergy testing and SCIT for ITR nonresponders. Results were reported as incremental cost-effectiveness ratios (ICERs).For patients who fail initial pharmacotherapy, prioritizing ITR, either by microdebrider-assisting submucous resection or radiofrequency ablation, before SCIT was the most cost-effective strategy. Probabilistic sensitivity analysis demonstrated that prioritizing ITR before SCIT was the most cost-effective option in 95.4% of scenarios. ITR remained cost-effective even with the addition of concurrent septoplasty.For many AR patients who present with nasal obstruction secondary to atopic inferior turbinate hypertrophy that is persistent despite pharmacotherapy, ITR is a cost-effective treatment that should be considered prior to immunotherapy.N/A - Laryngoscope, 2023 Laryngoscope, 2023.

    View details for DOI 10.1002/lary.31003

    View details for PubMedID 37642388

  • Environmental Risk Factors for Pediatric Epistaxis vary by Climate Zone. The Laryngoscope Wei, E. X., Green, A., Chang, M. T., Hwang, P. H., Sidell, D. R., Qian, Z. J. 2023

    Abstract

    Prior studies have provided variable results regarding environmental risk factors for epistaxis. These studies were conducted in varying climate zones, which may explain discrepancies in results. The objective of this study is to investigate correlations between season, temperature, and humidity on frequency of pediatric epistaxis across climate zones.Children seen in the outpatient setting for epistaxis were identified from the 2007-2010 IBM MarketScan database. Climate zones were assigned according to International Energy Conservation Code (IECC) classification, where temperature zones in the United States and territories were assigned on an ordinal scale from 1 (tropical) to 8 (subarctic), and humidity zones were categorized as moist, dry, or marine. The control population was a sample of all well-child visits matched by age and county.We identified 184,846 unique children seen for epistaxis and 1,897,012 matched controls. Moderate temperature zones were associated with lower odds of epistaxis compared with the hottest and coldest zones. Humidity was associated inversely with epistaxis rates in moderate temperature zones but was not a significant predictor of epistaxis in climates with extreme heat. Additionally, summer was associated with lower odds of epistaxis compared to winter. Interestingly, however, there were significantly higher rates of cautery procedures during summer months, driven largely by increased procedures performed in clinic, as opposed to the operating room or emergency room.Environmental risk factors for epistaxis vary by climate zone. The model presented reconciles prior reports and may allow for more personalized clinical management based on regional climate.Level 3 Laryngoscope, 2023.

    View details for DOI 10.1002/lary.30961

    View details for PubMedID 37589269

  • Multicenter Survival Analysis and Application of an Olfactory Neuroblastoma Staging Modification Incorporating Hyams Grade. JAMA otolaryngology-- head & neck surgery Choby, G., Geltzeiler, M., Almeida, J. P., Champagne, P. O., Chan, E., Ciporen, J., Chaskes, M. B., Fernandez-Miranda, J., Gardner, P., Hwang, P., Ji, K. S., Kalyvas, A., Kong, K. A., McMillan, R., Nayak, J., O'Byrne, J., Patel, C., Patel, Z., Peris Celda, M., Pinheiro-Neto, C., Sanusi, O., Snyderman, C., Thorp, B. D., Van Gompel, J. J., Young, S. C., Zenonos, G., Zwagerman, N. T., Wang, E. W. 2023

    Abstract

    Current olfactory neuroblastoma (ONB) staging systems inadequately delineate locally advanced tumors, do not incorporate tumor grade, and poorly estimate survival and recurrence.The primary aims of this study were to (1) examine the clinical covariates associated with survival and recurrence of ONB in a modern-era multicenter cohort and (2) incorporate Hyams tumor grade into existing staging systems to assess its ability to estimate survival and recurrence.This retrospective, multicenter, case-control study included patients with ONB who underwent treatment between January 1, 2005, and December 31, 2021, at 9 North American academic medical centers.Standard-of-care ONB treatment.The main outcomes were overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) as C statistics for model prediction.A total of 256 patients with ONB (mean [SD] age, 52.0 [15.6] years; 115 female [44.9%]; 141 male [55.1%]) were included. The 5-year rate for OS was 83.5% (95% CI, 78.3%-89.1%); for DFS, 70.8% (95% CI, 64.3%-78.0%); and for DSS, 94.1% (95% CI, 90.5%-97.8%). On multivariable analysis, age, American Joint Committee on Cancer (AJCC) stage, involvement of bilateral maxillary sinuses, and positive margins were associated with OS. Only AJCC stage was associated with DFS. Only N stage was associated with DSS. When assessing the ability of staging systems to estimate OS, the best-performing model was the novel modification of the Dulguerov system (C statistic, 0.66; 95% CI, 0.59-0.76), and the Kadish system performed most poorly (C statistic, 0.57; 95% CI, 0.50-0.63). Regarding estimation of DFS, the modified Kadish system performed most poorly (C statistic, 0.55; 95% CI, 0.51-0.66), while the novel modification of the AJCC system performed the best (C statistic, 0.70; 95% CI, 0.66-0.80). Regarding estimation of DSS, the modified Kadish system was the best-performing model (C statistic, 0.79; 95% CI, 0.70-0.94), and the unmodified Kadish performed the worst (C statistic, 0.56; 95% CI, 0.51-0.68). The ability for novel ONB staging systems to estimate disease progression across stages was also assessed. In the novel Kadish staging system, patients with stage VI disease were approximately 7 times as likely to experience disease progression as patients with stage I disease (hazard ratio [HR], 6.84; 95% CI, 1.60-29.20). Results were similar for the novel modified Kadish system (HR, 8.99; 95% CI, 1.62-49.85) and the novel Dulguerov system (HR, 6.86; 95% CI, 2.74-17.18).The study findings indicate that 5-year OS for ONB is favorable and that incorporation of Hyams grade into traditional ONB staging systems is associated with improved estimation of disease progression.

    View details for DOI 10.1001/jamaoto.2023.1939

    View details for PubMedID 37535372

  • International Multicenter Study of Clinical Outcomes of Sinonasal Melanoma Shows Survival Benefit for Patients Treated with Immune Checkpoint Inhibitors and Potential Improvements to the Current TNM Staging System. Journal of neurological surgery. Part B, Skull base Lechner, M., Takahashi, Y., Turri-Zanoni, M., Ferrari, M., Liu, J., Counsell, N., Mattavelli, D., Rampinelli, V., Vermi, W., Lombardi, D., Saade, R., Park, K. W., Schartinger, V. H., Franchi, A., Facco, C., Sessa, F., Battocchio, S., Fenton, T. R., Vaz, F. M., O'Flynn, P., Howard, D., Stimpson, P., Wang, S., Hannan, S. A., Unadkat, S., Hughes, J., Dwivedi, R., Forde, C. T., Randhawa, P., Gane, S., Joseph, J., Andrews, P. J., Dave, M., Fleming, J. C., Thomson, D., Zhu, T., Teschendorff, A., Royle, G., Steele, C., Jimenez, J. E., Laco, J., Wang, E. W., Snyderman, C., Lacy, P. D., Woods, R., O'Neill, J. P., Saraswathula, A., Kaur, R. P., Zhao, T., Ramanathan, M., Gallia, G. L., London, N. R., Le, Q. T., West, R. B., Patel, Z. M., Nayak, J. V., Hwang, P. H., Hermsen, M., Llorente, J., Facchetti, F., Nicolai, P., Bossi, P., Castelnuovo, P., Jay, A., Carnell, D., Forster, M. D., Bell, D. M., Lund, V. J., Hanna, E. Y. 2023; 84 (4): 307-319

    Abstract

    Objectives  Sinonasal mucosal melanoma (SNMM) is an extremely rare and challenging sinonasal malignancy with a poor prognosis. Standard treatment involves complete surgical resection, but the role of adjuvant therapy remains unclear. Crucially, our understanding of its clinical presentation, course, and optimal treatment remains limited, and few advancements in improving its management have been made in the recent past. Methods  We conducted an international multicenter retrospective analysis of 505 SNMM cases from 11 institutions across the United States, United Kingdom, Ireland, and continental Europe. Data on clinical presentation, diagnosis, treatment, and clinical outcomes were assessed. Results  One-, three-, and five-year recurrence-free and overall survival were 61.4, 30.6, and 22.0%, and 77.6, 49.2, and 38.3%, respectively. Compared with disease confined to the nasal cavity, sinus involvement confers significantly worse survival; based on this, further stratifying the T3 stage was highly prognostic ( p  < 0.001) with implications for a potential modification to the current TNM staging system. There was a statistically significant survival benefit for patients who received adjuvant radiotherapy, compared with those who underwent surgery alone (hazard ratio [HR] = 0.74, 95% confidence interval [CI]: 0.57-0.96, p  = 0.021). Immune checkpoint blockade for the management of recurrent or persistent disease, with or without distant metastasis, conferred longer survival (HR = 0.50, 95% CI: 0.25-1.00, p  = 0.036). Conclusions  We present findings from the largest cohort of SNMM reported to date. We demonstrate the potential utility of further stratifying the T3 stage by sinus involvement and present promising data on the benefit of immune checkpoint inhibitors for recurrent, persistent, or metastatic disease with implications for future clinical trials in this field.

    View details for DOI 10.1055/s-0042-1750178

    View details for PubMedID 37405239

    View details for PubMedCentralID PMC10317567

  • Incidence of hypocortisolism with long-term budesonide irrigations for chronic rhinosinusitis. International forum of allergy & rhinology Silva, B. R., Tyler, M. A., Ma, Y., Wang, J., Nayak, J. V., Patel, Z. M., Hwang, P. H. 2023

    Abstract

    Budesonide irrigations (BI) are commonly used to control inflammation in chronic rhinosinusitis (CRS). In 2016 we reported an analysis of long-term budesonide irrigation with regard to hypothalamic-pituitary-adrenal axis function. We present a follow-up analysis in a larger cohort of patients with longer follow-up.Patients were candidates for stimulated cortisol testing after regularly performing BI for CRS at least daily for ≥ 6 months. We retrospectively evaluated all patients who received stimulated cortisol testing at our center between 2012-22. We correlated cortisol levels with use of BI and other forms of corticosteroids.We analyzed 401 cortisol test results in 285 patients. The mean duration of use was 34 months. Overall, 21.8% of patients were hypocortisolemic (<18 ug/dL) at first test. In patients who used only BI the rate of hypocortisolemia was 7.5%, whereas in patients who also used concurrent oral and inhaled corticosteroids, the rate was 40-50%. Lower cortisol levels were associated with male gender (p<.0001) and concomitant use of oral and inhaled steroids (p<.0001). Duration of budesonide irrigation use was not significantly associated with lower cortisol levels (p = 0.701), nor was greater dosing frequency (p = 0.289).Prolonged use of BI alone is not likely to cause hypocortisolemia in the majority of patients. However, concomitant use of inhaled and oral steroids, and male gender may be associated with hypocortisolemia. Surveillance of cortisol levels may be considered in vulnerable populations who use budesonide irrigations regularly, particularly in patients using other forms of corticosteroids with known systemic absorption. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23227

    View details for PubMedID 37389470

  • Endoscopic Endonasal Transtuberculum Approach for Pediatric Tuberoinfundibular Craniopharyngioma: 2-Dimensional Operative Video. Operative neurosurgery (Hagerstown, Md.) Vigo, V., Chang, J. E., Nunez, M. A., Prolo, L. M., Hwang, P. H., Fernandez-Miranda, J. C. 2023

    Abstract

    INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE: The endoscopic endonasal transtuberculum approach grants access to suprasellar and retrochiasmatic lesions with hypothalamic involvement. Here, we present a case of a 13-year-old boy with a history of stunted growth, decreased vision, headaches, and low energy with a tuberoinfundibular craniopharyngioma. The patient consented to the procedure.ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT: Evaluation of the sphenoid sinus pneumatization, internal carotid artery disposition, presence of clinoidal rings, variations of the infrachiasmatic corridor (optic chiasm location, height of dorsum sella), and location of the pituitary stalk are crucial for surgical strategy.ESSENTIALS STEPS OF THE PROCEDURE: Harvesting of nasoseptal flap and access to the sphenoid sinus; drilling the sella, tuberculum, and chiasmatic sulcus up to the limbus sphenoidalis and laterally exposing the clinoidal carotid artery segment; wide dural opening to the level of distal rings inferolaterally and falciform ligaments superolaterally; identification and coagulation of superior hypophyseal branches providing tumor supply; intracapsular dissection and debulking and subpial sharp dissection at the hypothalamic tumor interface to achieve complete removal; and reconstruction with inlay collagen, fascia lata, and nasoseptal flap.PITFALLS/AVOIDANCE OF COMPLICATIONS: Preservation of the superior hypophyseal arteries and stalk is essential for preventing pituitary dysfunction. Preoperative reckoning of hypothalamic invasion and identification of adequate interface aids in avoiding complications. To reduce CSF leak risk, multilayer reconstruction was performed and lumbar drain placed postoperatively.VARIANTS AND INDICATIONS FOR THEIR USE: For retroclival extension, intradural pituitary transposition should be considered to expand the corridor; in patients with preoperative hypopituitarism, pituitary sacrifice is most effective to increase retroclival access.

    View details for DOI 10.1227/ons.0000000000000726

    View details for PubMedID 37350589

  • Difficult Tracheal Intubation and Airway Outcomes after Radiation for Nasopharyngeal Carcinoma. The Laryngoscope Huang, A. E., Camire, D., Hwang, P. H., Nekhendzy, V. 2023

    Abstract

    OBJECTIVE: The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT).METHODS: The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group).RESULTS: One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p=0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p<0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%.CONCLUSION: NPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor.LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2023.

    View details for DOI 10.1002/lary.30767

    View details for PubMedID 37249176

  • THE EFFECT OF ACOUSTIC RESONANCE THERAPY ON CPAP ADHERENCE Munafo, D., Gopi, P., Mohan, V., Hwang, P., Lin, B., Hekier, E., Lane, B., Guerrero, C., Dauphin, B., Kushida, C. OXFORD UNIV PRESS INC. 2023: A216
  • Long-term quality of life after treatment in sinonasal malignancy: A prospective, multi-center study. International forum of allergy & rhinology Maoz, S. L., Wang, E. W., Hwang, P. H., Choby, G., Kuan, E. C., Fleseriu, C. M., Chan, E. P., Adappa, N. D., Geltzeiler, M., Getz, A. E., Humphreys, I. M., Le, C. H., Abuzeid, W. M., Chang, E. H., Jafari, A., Kingdom, T. T., Kohanski, M. A., Lee, J. K., Lazor, J. W., Nabavizadeh, A., Nayak, J. V., Palmer, J. N., Patel, Z. M., Pinheiro-Neto, C. D., Resnick, A. C., Smith, T. L., Snyderman, C. H., St John, M. A., Storm, P. B., Suh, J. D., Wang, M. B., Sim, M. S., Beswick, D. M. 2023

    Abstract

    Quality-of-life (QOL) for individuals with sinonasal malignancy (SNM) is significantly understudied yet critical for counseling and may impact treatment. This study evaluated the how patient, treatment, and disease factors impact sinonasal-specific and generalized QOL using validated metrics in a large cohort over a 5-year post-treatment timeframe.Patients with SNM who underwent definitive treatment with curative intent were enrolled into a prospective, multi-site, longitudinal observational study. QOL was assessed using the Sinonasal Outcome Test-22 (SNOT-22) and University of Washington Quality of Life Questionnaire (UWQOL) instruments at pre-treatment baseline and multiple follow-ups through 5 years post-treatment. Multivariable modelling was used to determine demographic, disease, and treatment factors associated with disease-specific and generalized physical and social/emotional function QOL.194 patients with SNM were analyzed. All QOL indices were impaired at pre-treatment baseline and improved post-treatment. SNOT-22 scores improved 3 months and UWQOL scores improved 6-9 months post-treatment. Patients who underwent open compared to endoscopic tumor resection had worse generalized QOL (p<0.001), adjusted for factors including T stage. Pterygopalatine fossa (PPF) involvement was associated with worse QOL (SNOT-22, p<0.001; UWQOL-Physical, p = 0.02). Adjuvant radiation was associated with worse disease-specific QOL (p = 0.03). Neck dissection was associated with worse generalized physical function QOL (p = 0.01). Positive margins were associated with worse generalized social/emotional function QOL (p = 0.01).Disease-specific and generalized QOL is impaired at baseline in patients with SNM and improves following treatment. Endoscopic resection is associated with better QOL. PPF involvement, adjuvant radiation, neck dissection, and positive margins were associated with worse QOL post-treatment. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23171

    View details for PubMedID 37082883

  • The Utility of a "Second-Look" Debridement Following Endonasal Skull Base Surgery in the Pediatric Population JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Chang, M. T., Huang, A. E., Quon, J. L., Fernandez-Miranda, J. C., Wen, C. Z., Eide, J. G., Kshirsagar, R. S., Qian, Z., Nayak, J. V., Hwang, P. H., Adappa, N. D., Patel, Z. M. 2023
  • Radiographic predictors of occult intracranial involvement in olfactory neuroblastoma patients. International forum of allergy & rhinology Geltzeiler, M., Choby, G. W., Ji, K. S., Mace, J. C., Almeida, J. P., de Almeida, J., Champagne, P., Chan, E., Ciporen, J. N., Chaskes, M. B., Cornell, S., Drozdowski, V., Fernandez-Miranda, J., Gardner, P. A., Hwang, P. H., Kalyvas, A., Kong, K. A., McMillan, R. A., Nayak, J. V., Patel, C., Patel, Z. M., Celda, M. P., Pinheiro-Neto, C., Sanusi, O. R., Snyderman, C. H., Thorp, B. D., Van Gompel, J. J., Zadeh, G., Zenonos, G., Zwagerman, N. T., Wang, E. W. 2023

    Abstract

    BACKGROUND: Traditional management of olfactory neuroblastoma (ONB) includes margin negative resection with removal of cribriform plate, dura, and olfactory bulb, regardless of intracranial disease. This approach may be over-treating certain patients. Our investigation examines risk factors associated with occult intracranial disease to optimize therapeutic outcomes.METHODS: This retrospective, multi-institutional cohort study examined clinical covariates associated with occult intracranial involvement. Patient demographics, staging, Hyam's grade and pathologic involvement of dura, olfactory bulb/tract and brain were collected. Diagnostic imaging was reviewed. Positive and negative predictive value (NPV) were estimated along with effect size estimates. Cox hazard regression examined associations with overall (OS) and disease-free survival (DFS).RESULTS: 224 subjects with new diagnoses of ONB (2005-2021) were identified. Skull base bone involvement on computed tomography (CT) had the highest NPV for pathologic dura (88.0%), olfactory bulb (88%), and brain involvement (97.3%). Hyam's grade category was significantly associated with dural involvement (phiC = 0.26; 95% CI: 0.16, 0.42). Subjects without radiologic skull base involvement (n = 66) had pathologic positivity of 12.1%. Within this subgroup, Hyam's grade was clinically significant for dural positivity (phi = 0.34; 95% CI: -0.12, 0.71) with 28.6% involvement in high grade tumors. Neither clinical nor pathologic positivity of intracranial structures were associated with significantly different OS or DFS.CONCLUSIONS: Both CT and MRI had reasonably good NPV for involvement of dura and olfactory bulb. Higher Hyam's grade was associated with dural involvement. Patients with low-grade tumors not involving the skull base may be suitable for avoiding skull base resection, however further investigation is warranted. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23145

    View details for PubMedID 36841933

  • Social Media Utilization in Otolaryngology: A Scoping Review. The Laryngoscope Huang, A. E., Chan, E. P., Stave, C. M., Patel, Z. M., Hwang, P. H., Chang, M. T. 2023

    Abstract

    OBJECTIVE: Social media (SM) is an increasingly popular medium for the medical community to engage with patients, trainees, and colleagues. This review aimed to identify reported uses of SM in otolaryngology-head and neck surgery (OHNS), assess the quality of evidence supporting these uses, and identify gaps in the literature. With the relative lack of regulatory guidelines for the development of SM content, we hypothesized that the quality of content available on SM would be highly variable.DATA SOURCES AND METHODS: A scoping review was performed of English-language peer-reviewed studies published to date discussing SM use in any form within OHNS. Three reviewers independently screened all abstracts. Two reviewers independently extracted data of interest from the full text of articles identified from the preliminary abstract screen.RESULTS: 171 studies were included, with 94 (54.9%) studies published between 2020 and 2022. 104 (60.8%) studies were conducted in the US. 135 (78.9%) used cross-sectional or survey-based methodology; only 7 (4.1%) were controlled studies. SM was most commonly employed for professional networking (n=37 [21%]), and within subspecialties of otology (n=38 [22%]) and rhinology/allergy (n=25 [15%]). Facebook was most frequently used for study recruitment (n=23 [13.5%]), YouTube for patient education (n=15 [14.6%]), and Twitter for professional networking (n=16 [9.4%]).CONCLUSION: SM use within OHNS is increasing rapidly, with applications including patient education, professional networking, and study recruitment. Despite myriad articles, there remains a paucity of well-controlled studies. As SM becomes integrated into healthcare, particularly for applications directly impacting patient care, higher levels of evidence are needed to understand its true impact. Laryngoscope, 2023.

    View details for DOI 10.1002/lary.30619

    View details for PubMedID 36807152

  • Oral Corticosteroid Burden and Healthcare Resource Utilization (HCRU) in Patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) Undergoing Functional Endoscopic Sinonasal Surgery (FESS): A Real-World Retrospective Cohort Study Isaman, D., Khan, A., Lee, S., Peters, A., Hwang, P., Reitsma, S., Petruski-Ivleva, N., Nash, S., Jacob-Nara, J. MOSBY-ELSEVIER. 2023: AB201
  • Characteristics of Patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) Who Did or Did Not Undergo Functional Endoscopic Sinus Surgery (FESS) in a US Real-World Retrospective Cohort Study Khan, A., Isaman, D., Lee, S., Peters, A., Hwang, P., Reitsma, S., Petruski-Ivleva, N., Nash, S., Jacob-Nara, J. MOSBY-ELSEVIER. 2023: AB203
  • Diagnosis, prognosticators, and management of acute invasive fungal rhinosinusitis: multidisciplinary consensus statement and Evidence-Based review with recommendations. International forum of allergy & rhinology Roland, L. T., Humphreys, I. M., Le, C. H., Babik, J. M., Bailey, C. E., Ediriwickrema, L. S., Fung, M., Lieberman, J. A., Magliocca, K. R., Nam, H. H., Teo, N. W., Thomas, P. C., Winegar, B. A., Birkenbeuel, J. L., David, A. P., Goshtasbi, K., Johnson, P. G., Martin, E. C., Nguyen, T. V., Patel, N. N., Qureshi, H. A., Tay, K., Vasudev, M., Abuzeid, W. M., Hwang, P. H., Jafari, A., Russell, M. S., Turner, J. H., Wise, S. K., Kuan, E. C. 2023

    Abstract

    Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS.The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated.Review and evaluation of published literature was performed on twelve topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains.Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23132

    View details for PubMedID 36680469

  • Tranexamic acid does not significantly lower postoperative bleeding after endoscopic sinus and nasal surgery. International forum of allergy & rhinology Khanwalkar, A., Chan, E., Roozdar, P., Kim, D., Ma, Y., Hwang, P. H., Nayak, J. V., Patel, Z. M. 2023

    Abstract

    BACKGROUND: Postoperative epistaxis is a known possibility following endoscopic sinonasal surgery. Tranexamic acid (TXA) has been shown to reduce intraoperative blood loss and improve the visual field. This study evaluates the clinical efficacy of TXA when given at end of surgery to reduce postoperative bleeding.METHODS: This randomized, double-blinded placebo-controlled trial was conducted from April to November 2021. Patients scheduled to undergo endoscopic sinus or nasal surgery were randomized to receive an intravenous dose of 1g TXA or saline intraoperatively prior to extubation. A 10-inch visual analog scale (VAS) was used to query patients regarding postoperative bleeding each day for one week. The medical record was examined to determine the need for additional evaluations or interventions for epistaxis.RESULTS: 40 patients completed the study. The mean/SD postoperative bleeding VAS for the TXA group on the day of surgery was not significantly different from the saline group (4.82 [2.18] in vs 5.03 [2.14] in, p = 0.8). There were no significant differences between treatment arms on any postoperative day through day 7 (0.67 [1.84] in vs 0.87 [0.99] in, p = 0.7), nor in the reduction in VAS compared to the respective baseline on the day of surgery. There were no significant differences in terms of additional interventions (e.g. additional evaluation in recovery, ED, or clinic, need for packing, or return to OR).CONCLUSION: While TXA has previously demonstrated efficacy to reduce intraoperative bleeding during sinonasal surgery, when postoperative bleeding is already minimal at baseline, TXA does not appear to reduce it significantly further. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23127

    View details for PubMedID 36608352

  • Rhinolithiasis misdiagnosed as intranasal osteoma: Diagnostic challenges in the telehealth era. SAGE open medical case reports Kiessling, P., Hwang, P., Chang, M. 2023; 11: 2050313X231207204

    Abstract

    Rhinolithiasis is a rare clinical presentation and may be a diagnostic challenge, often mimicking other intranasal pathologies and difficult to differentiate based on imaging alone. We present the case of a 50-year-old patient with rhinolithiasis who presented with chronic left nasal obstruction and unilateral cyclic pain with foul discharge. After review of her imaging, she was initially misdiagnosed with an intranasal osteoma via telehealth and scheduled for surgical resection. Her true pathology of rhinolithiasis was subsequently identified and treated during an in-person pre-operative clinic visit. In this case report, we review the key characteristic elements of rhinolithiasis presentation, and in doing so, we reveal the limitations inherent to telehealth evaluations, and the considerations needed to be taken into account by providers evaluating intranasal lesions. Specifically, in-person assessment with a detailed endoscopy is critical as part of the complete workup of nasal cavity lesions.

    View details for DOI 10.1177/2050313X231207204

    View details for PubMedID 37860281

  • The link between allergic rhinitis and chronic rhinosinusitis. Current opinion in otolaryngology & head and neck surgery Grimm, D., Hwang, P. H., Lin, Y. 2022

    Abstract

    PURPOSE OF REVIEW: Allergic rhinitis and chronic rhinosinusitis (CRS) are common disorders affecting millions of people worldwide. Although allergic rhinitis and CRS are distinct clinical entities, certain CRS endotypes share similar pathological mechanisms as those seen in patients with allergic rhinitis. This review assesses the literature behind the similarities and differences seen in patients with CRS and allergic rhinitis, and the role atopy might play in the pathophysiology of CRS.RECENT FINDINGS: In examining the associations between allergic rhinitis and CRS, most studies have focused primarily on CRS with nasal polyps and type 2 inflammation in CRS. Recent studies have demonstrated the similarities and differences in pathologic mechanisms behind allergic rhinitis and CRS, with an emphasis on patient endotypes, genetics, and the nasoepithelial immunologic barrier. Related immunopathology shared by allergic rhinitis and type 2 inflammation in CRS has allowed for therapeutic overlap with biologic treatments.SUMMARY: Allergic rhinitis and CRS often present as comorbid conditions, and understanding the relationship between allergic rhinitis and CRS is important when considering treatment options. Advances in understanding the genetics and immunology, as well as biologic and immunotherapeutic treatments have improved outcomes in patients with CRS, especially in the setting of atopy.

    View details for DOI 10.1097/MOO.0000000000000865

    View details for PubMedID 36729858

  • High prevalence of persistent smell loss and qualitative smell dysfunction during the COVID-19 pandemic in the United States: urgent need for clinical trials. International forum of allergy & rhinology Lechner, M., Liu, J., Counsell, N., Yan, C. H., Paun, S., Eynon-Lewis, N., Sutton, L., Jayaraj, S., Batterham, R. L., Hopkins, C., Philpott, C., Lund, V. J., Hatter, M., Abdelwahab, M., Holsinger, F. C., Capasso, R., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2022

    View details for DOI 10.1002/alr.23100

    View details for PubMedID 36409559

  • Effect of dupilumab on Eustachian tube dysfunction in patients with chronic rhinosinusitis with nasal polyposis. International forum of allergy & rhinology Chang, M., Roozdar, P., Lin, Y. T., Lee, J. Y., Nayak, J. V., Patel, Z. M., Hwang, P. H. 2022

    View details for DOI 10.1002/alr.23110

    View details for PubMedID 36399364

  • Endoscopic Skull Base Surgery in Children CURRENT OTORHINOLARYNGOLOGY REPORTS Low, C. M., Hwang, P. H. 2022
  • International Multicenter Study of Clinical Outcomes of Sinonasal Melanoma Shows Survival Benefit for Patients Treated with Immune Checkpoint Inhibitors and Potential Improvements to the Current TNM Staging System JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Lechner, M., Takahashi, Y., Turri-Zanoni, M., Ferrari, M., Liu, J., Counsell, N., Mattavelli, D., Rampinelli, V., Vermi, W., Lombardi, D., Saade, R., Park, K., Schartinger, V. H., Franchi, A., Facco, C., Sessa, F., Battocchio, S., Fenton, T. R., Vaz, F. M., O'Flynn, P., Howard, D., Stimpson, P., Wang, S., Hannan, S., Unadkat, S., Hughes, J., Dwivedi, R., Forde, C. T., Randhawa, P., Gane, S., Joseph, J., Andrews, P. J., Dave, M., Fleming, J. C., Thomson, D., Zhu, T., Teschendorff, A., Royle, G., Steele, C., Jimenez, J. E., Laco, J., Wang, E. W., Snyderman, C., Lacy, P. D., Woods, R., O'Neill, J. P., Saraswathula, A., Kaur, R., Zhao, T., Ramanathan, M., Gallia, G. L., London, N. R., Le, Q., West, R. B., Patel, Z. M., Nayak, J. V., Hwang, P. H., Hermsen, M., Llorente, J., Facchetti, F., Nicolai, P., Bossi, P., Castelnuovo, P., Jay, A., Carnell, D., Forster, M. D., Bell, D. M., Lund, V. J., Hanna, E. Y. 2022
  • Prospective intraoperative and histologic evaluation of cavernous sinus medial wall invasion by pituitary adenomas and its implications for acromegaly remission outcomes. Scientific reports Mohyeldin, A., Katznelson, L. J., Hoffman, A. R., Asmaro, K., Ahmadian, S. S., Eltobgy, M. M., Nayak, J. V., Patel, Z. M., Hwang, P. H., Fernandez-Miranda, J. C. 2022; 12 (1): 9919

    Abstract

    Recurrence and biochemical remission rates vary widely among different histological subtypes of pituitary adenoma. In this prospective study, we evaluated 107 consecutive primary pituitary adenomas operated on by a single neurosurgeon including 28 corticotroph, 27 gonadotroph, 24 somatotroph, 17 lactotroph, 5 null-cell and 6 plurihormonal. In each case, we performed direct endoscopic intraoperative inspection of the medial wall of the cavernous sinus, which was surgically removed when invasion was visualized. This was performed irrespective of tumor functional status. Medial wall resection was performed in 47% of pituitary adenomas, and 39/50 walls confirmed pathologic evidence of invasion, rendering a positive predictive value of intraoperative evaluation of medial wall invasion of 78%. We show for the first-time dramatic disparities in the frequency of medial wall invasion among pathological subtypes. Somatotroph tumors invaded the medial wall much more often than other adenoma subtypes, 81% intraoperatively and 69% histologically, followed by plurihormonal tumors (40%) and gonadotroph cell tumors (33%), both with intraoperative positive predictive value of 100%. The least likely to invade were corticotroph adenomas, at a rate of 32% intraoperatively and 21% histologically, and null-cell adenomas at 0%. Removal of the cavernous sinus medial wall was not associated with permanent cranial nerve morbidity nor carotid artery injury, although 4 patients (all Knosp 3-4) experienced transient diplopia. Medial wall resection in acromegaly resulted in the highest potential for biochemical remission ever reported, with an average postoperative day 1 GH levels of 0.96 ug/L and surgical remission rates of 92% based on normalization of IGF-1 levels after surgery (mean = 15.56 months; range 3-30 months). Our findings suggest that tumor invasion of the medial wall of the cavernous sinus may explain the relatively low biochemical remission rates currently seen for acromegaly and illustrate the relevance of advanced intradural surgical approaches for successful and durable outcomes in endonasal pituitary surgery for functional adenomas.

    View details for DOI 10.1038/s41598-022-12980-1

    View details for PubMedID 35705579

  • Applications of vibrational energy in the treatment of sinonasal disease: A scoping review. International forum of allergy & rhinology Phillips, K. M., Roozdar, P., Hwang, P. H. 2022

    Abstract

    BACKGROUND: Acoustic energy and vibration therapy are emerging as helpful adjuncts across many disease states. There has been interest in how this technology can either serve as an alternative treatment or enhance delivery of medications to treat pathology within the nasal cavity and paranasal sinuses. Our objective was to perform a scoping review of the state of the science of vibration treatment used in sinonasal disease.METHODS: A search of Embase, Pubmed and CINAHL databases was performed in November 2021. Included studies evaluated acoustic energy as a means of treatment in sinonasal diseases. Datapoints collected included type of technology utilized, disease state treated and outcomes.RESULTS: The initial search identified 2902 studies, of which 44 met inclusion criteria. A wide array of vibrational technology such as ultrasound, sonic aerosols or phonophoresis, with varying frequency and amplitude were described. 26 studies evaluated the use of acoustic energy to treat sinonasal disease itself, while 18 studies evaluated the use of acoustic energy to facilitate drug delivery to the sinonasal cavity. Outcome measures across studies were highly varied.CONCLUSIONS: Vibration technology used in patients with sinonasal pathology has been shown to improve pain, sinonasal symptoms and radiologic outcome measures in small studies. Given the heterogeneous study populations and outcomes, no conclusion could be reached regarding overall effectiveness of acoustic energy as a primary treatment. Further research is required to study specific treatment indications in larger patient populations to fully understand the potential clinical benefit and to determine optimal therapeutic characteristics of sound energy. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22988

    View details for PubMedID 35218159

  • Skull base osteomyelitis in patients with head and neck cancer: Diagnosis, management, and outcomes in a case series of 23 patients. Laryngoscope investigative otolaryngology Czech, M. M., Hwang, P. H., Colevas, A. D., Fischbein, N., Ho, D. Y. 2022; 7 (1): 47-59

    Abstract

    Skull base osteomyelitis (SBO) is an infection of the central cranial bones, most commonly resulting from contiguous spread of infection from adjacent head and neck structures. SBO is a well-recognized complication of treatment of head and neck cancer (HNC) that results in significant morbidity.We conducted a retrospective chart review of HNC patients diagnosed with SBO.SBO was commonly diagnosed with nasal endoscopy showing mucosal breakdown between the naso/oropharynx and skull base and with characteristic changes on CT/MRI. Culture data were often polymicrobial, inclusive of naso/oropharyngeal flora, but half of the patients additionally had antibiotic-resistant or atypical pathogens. The mean duration of antimicrobial therapy was 117 +/- 94 days. Recurrent SBO was found in half of the patients, associated with Pseudomonas aeruginosa and with persistent defects in the mucosa abutting the skull base.Diagnosis and management of SBO in HNC patients are challenging. Recommendations to aid in clinical care are proposed.4, case series.

    View details for DOI 10.1002/lio2.719

    View details for PubMedID 35155783

    View details for PubMedCentralID PMC8823154

  • Skull base osteomyelitis in patients with head and neck cancer: Diagnosis, management, and outcomes in a case series of 23 patients LARYNGOSCOPE INVESTIGATIVE OTOLARYNGOLOGY Czech, M. M., Hwang, P. H., Colevas, A., Fischbein, N., Ho, D. Y. 2022

    View details for DOI 10.1002/lio2.719

    View details for Web of Science ID 000738559200001

  • Deep learning classification of inverted papilloma malignant transformation using 3D convolutional neural networks and magnetic resonance imaging. International forum of allergy & rhinology Liu, G. S., Yang, A., Kim, D., Hojel, A., Voevodsky, D., Wang, J., Tong, C. C., Ungerer, H., Palmer, J. N., Kohanski, M. A., Nayak, J. V., Hwang, P. H., Adappa, N. D., Patel, Z. M. 2022

    Abstract

    Distinguishing benign inverted papilloma (IP) tumors from those that have undergone malignant transformation to squamous cell carcinoma (IP-SCC) is important but challenging to do preoperatively. Magnetic resonance imaging (MRI) can help differentiate these two entities, however no established method exists that can automatically synthesize all potentially relevant MRI image features to distinguish IP and IP-SCC. We explored a deep learning approach, using 3-dimensional convolutional neural networks (CNNs), to address this challenge.Retrospective chart reviews were performed at two institutions to create a dataset of preoperative MRIs with corresponding surgical pathology reports. The MRI dataset included all available MRI sequences in the axial plane, which were used to train, validate, and test three CNN models. Saliency maps were generated to visualize areas of MRIs with greatest influence on predictions.A total of 90 patients with IP (n = 64) or IP-SCC (n = 26) tumors were identified, with a total of 446 images of distinct MRI sequences for IP (n = 329) or IP-SCC (n = 117). The best CNN model, All-Net, demonstrated a sensitivity of 66.7%, specificity of 81.5%, overall accuracy of 77.9%, and ROC-AUC of 0.80 ([0.682 - 0.898], 95% confidence interval) for test classification performance. The other two models, Small-All-Net and Elastic-All-Net, showed similar performances.A deep learning approach with 3-dimensional CNNs can distinguish IP and IP-SCC with moderate test classification performance. Although CNNs demonstrate promise to enhance the prediction of IP-SCC using MRIs, more data is needed before they can reach the predictive value already established by human MRI evaluation. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22958

    View details for PubMedID 34989484

  • Open and endoscopic surgery improve survival for squamous and non-squamous cell nasopharyngeal carcinomas: an NCDB cohort study. International forum of allergy & rhinology Finegersh, A., Said, M., Deconde, A., Hwang, P. H., Holsinger, F. C., Orosco, R. K. 2022

    Abstract

    Nasopharyngeal tumors (NPT) are primarily treated with nonsurgical therapy. Recent studies have demonstrated endoscopic salvage surgery for NPT recurrences may improve survival relative to re-irradiation. However, there is very limited data on open compared to endoscopic approaches for NPT. We investigated whether endoscopic and open surgical approaches to the nasopharynx improve overall survival for all histologic subtypes of NPT.A retrospective cohort study using the National Cancer Database (NCDB) was performed. All adult patients with NPT from 2004 - 2016 without distant metastasis who underwent treatment with curative intent were included. We extracted clinical and treatment variables to assess our primary outcome of overall survival.On univariate analysis, patients undergoing endoscopic surgery but not open surgery had significantly improved overall survival relative to those undergoing nonsurgical treatment. Post hoc analysis demonstrated significantly improved overall survival for surgery in patients with minor salivary gland histology but not squamous cell carcinoma (SCC) histology or by T- or N-classification. A Cox proportional hazards model was used for multivariate regression. After adjusting for covariates, both endoscopic and open approaches were associated with improved overall survival relative to nonsurgical treatment for all tumor types. A multivariate regression of SCC found that open but not endoscopic surgery was significantly associated with improved overall survival.Both endoscopic and open surgical approaches are associated with improved overall survival of patients with NPT. These findings offer important oncologic validity as endoscopic and robotic platforms to the nasopharynx become more widely adopted. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23000

    View details for PubMedID 35313077

  • Telemedicine and Telementoring in Rhinology, Otology, and Laryngology: A Scoping Review. OTO open Yang, A., Kim, D., Hwang, P. H., Lechner, M. 2022; 6 (1): 2473974X211072791

    Abstract

    Objective: Telemedicine and telementoring have had a significant boost across all medical and surgical specialties over the last decade and especially during the COVID-19 pandemic. The aim of this scoping review is to synthesize the current use of telemedicine and telementoring in otorhinolaryngology and head and neck surgery.Data Sources: PubMed and Cochrane Library.Review Methods: A scoping review search was conducted, which identified 469 articles. Following full-text screening by 2 researchers, 173 articles were eligible for inclusion and further categorized via relevant subdomains.Conclusions: Virtual encounters and telementoring are the 2 main applications of telemedicine in otolaryngology. These applications can be classified into 7 subdomains. Different ear, nose, and throat subspecialties utilized certain telemedicine applications more than others; for example, almost all articles on patient engagement tools are rhinology based. Overall, telemedicine is feasible, showing similar concordance when compared with traditional methods; it is also cost-effective, with high patient and provider satisfaction.Implications for Practice: Telemedicine in otorhinolaryngology has been widely employed during the COVID-19 pandemic and has a huge potential, especially with regard to its distributing quality care to rural areas. However, it is important to note that with current exponential use, it is equally crucial to ensure security and privacy and integrate HIPAA-compliant systems (Health Insurance Portability and Accountability Act) in the big data era. It is expected that many more applications developed during the pandemic are here to stay and will be refined in years to come.

    View details for DOI 10.1177/2473974X211072791

    View details for PubMedID 35274073

  • Randomized controlled double-blinded clinical trial of the effect of bevacizumab injection in the management of epistaxis in HHT patients undergoing surgical cauterization. International forum of allergy & rhinology Khanwalkar, A. R., Rathor, A., Read, A. K., Ma, Y., Hwang, P. H. 2022

    Abstract

    Given its role in the disease pathophysiology, inhibition of VEGF-mediated angiogenesis has received attention as a potential strategy to reduce epistaxis associated with hereditary hemorrhagic telangiectasia (HHT). This study evaluates the efficacy of a submucosal injection of bevacizumab, a VEGF-inhibitor, in reducing the severity of epistaxis and improving quality of life when given at the time of operative electrocautery.This randomized, double-blinded placebo-controlled trial was conducted at a single institution from 2014 to 2019. Patients scheduled to undergo operative bipolar electrocautery of nasal telangiectasias were randomized to receive a submucosal injection of saline or bevacizumab at time of surgery. Surveys to assess epistaxis severity and quality-of-life (QOL), including the Epistaxis Severity Score (ESS) and Short Form 12 (SF-12), were administered preoperatively and at 1, 2, 4, and 6 months postoperatively. The minimal clinically important difference (MCID) of the ESS instrument is reported to be 0.71.Of 39 patients enrolled, 37 (94.9%) completed the study. The saline group demonstrated reduced ESS versus baseline at 1 (-1.2, p = 0.01) and 4 (-1.2, p = 0.05) months post-procedure. The bevacizumab group demonstrated reduced ESS versus baseline at 1 (-2.3, p<0.001), 2 (-2.3, p<0.001), 4 (-2.0, p = 0.003), and 6 (-1.3, p = 0.05) months post-procedure. The additive benefit of bevacizumab over saline exceeded the MCID at 1, 2, and 4 months but the difference was not statistically significant.The addition of a single treatment of submucosal bevacizumab may be associated with additional clinically meaningful benefit for up to 4 months when compared to electrocautery alone. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22961

    View details for PubMedID 34989143

  • Clinical outcomes, Kadish-INSICA staging and therapeutic targeting of somatostatin receptor 2 in olfactory neuroblastoma. European journal of cancer (Oxford, England : 1990) Lechner, M., Takahashi, Y., Turri-Zanoni, M., Liu, J., Counsell, N., Hermsen, M., Kaur, R. P., Zhao, T., Ramanathan, M. J., Schartinger, V. H., Emanuel, O., Helman, S., Varghese, J., Dudas, J., Riechelmann, H., Sprung, S., Haybaeck, J., Howard, D., Engel, N. W., Stewart, S., Brooks, L., Pickles, J. C., Jacques, T. S., Fenton, T. R., Williams, L., Vaz, F. M., O'Flynn, P., Stimpson, P., Wang, S., Hannan, S. A., Unadkat, S., Hughes, J., Dwivedi, R., Forde, C. T., Randhawa, P., Gane, S., Joseph, J., Andrews, P. J., Royle, G., Franchi, A., Maragliano, R., Battocchio, S., Bewicke-Copley, H., Pipinikas, C., Webster, A., Thirlwell, C., Ho, D., Teschendorff, A., Zhu, T., Steele, C. D., Pillay, N., Vanhaesebroeck, B., Mohyeldin, A., Fernandez-Miranda, J., Park, K. W., Le, Q., West, R. B., Saade, R., Manes, R. P., Omay, S. B., Vining, E. M., Judson, B. L., Yarbrough, W. G., Sansovini, M., Silvia, N., Grassi, I., Bongiovanni, A., Capper, D., Schuller, U., Thavaraj, S., Sandison, A., Surda, P., Hopkins, C., Ferrari, M., Mattavelli, D., Rampinelli, V., Facchetti, F., Nicolai, P., Bossi, P., Henriquez, O. A., Magliocca, K., Solares, C. A., Wise, S. K., Llorente, J. L., Patel, Z. M., Nayak, J. V., Hwang, P. H., Lacy, P. D., Woods, R., O'Neill, J. P., Jay, A., Carnell, D., Forster, M. D., Ishii, M., London, N. R., Bell, D. M., Gallia, G. L., Castelnuovo, P., Severi, S., Lund, V. J., Hanna, E. Y. 1800

    Abstract

    INTRODUCTION: Olfactory neuroblastoma (ONB) is a rare cancer of the sinonasal region. We provide a comprehensive analysis of this malignancy with molecular and clinical trial data on a subset of our cohort to report on the potential efficacy of somatostatin receptor 2 (SSTR2)-targeting imaging and therapy.METHODS: We conducted a retrospective analysis of 404 primary, locally recurrent, and metastatic olfactory neuroblastoma (ONB) patients from 12 institutions in the United States of America, United Kingdom and Europe. Clinicopathological characteristics and treatment approach were evaluated. SSTR2 expression, SSTR2-targeted imaging and the efficacy of peptide receptor radionuclide therapy [PRRT](177Lu-DOTATATE) were reported in a subset of our cohort (LUTHREE trial; NCT03454763).RESULTS: Dural infiltration at presentation was a significant predictor of overall survival (OS) and disease-free survival (DFS) in primary cases (n=278). Kadish-Morita staging and Dulguerov T-stage both had limitations regarding their prognostic value. Multivariable survival analysis demonstrated improved outcomes with lower stage and receipt of adjuvant radiotherapy. Prophylactic neck irradiation significantly reduces the rate of nodal recurrence. 82.4% of the cohort were positive for SSTR2; treatment of three metastatic cases with SSTR2-targeted peptide-radionuclide receptor therapy (PRRT) in the LUTHREE trial was well-tolerated and resulted in stable disease (SD).CONCLUSIONS: This study presents pertinent clinical data from the largest dataset, to date, on ONB. We identify key prognostic markers and integrate these into an updated staging system, highlight the importance of adjuvant radiotherapy across all disease stages, the utility of prophylactic neck irradiation and the potential efficacy of targeting SSTR2 to manage disease.

    View details for DOI 10.1016/j.ejca.2021.09.046

    View details for PubMedID 34980502

  • Venous thromboembolism rates and risk factors following endoscopic skull base surgery. International forum of allergy & rhinology Chang, M. T., Jitaroon, K., Song, S., Roozdar, P., Wangworat, Y., Ibrahim, N., Ma, Y., Rao, V. K., Chang, S. D., Fernandez-Miranda, J. C., Patel, Z. M., Dodd, R. L., Hwang, P. H., Harsh, G. R., Nayak, J. V. 2021

    Abstract

    BACKGROUND: Venous thromboembolism (VTE) is a potentially fatal perioperative complication. The objective of this study was to assess the rate and risk factors for VTE in endoscopic skull base surgery (ESBS).METHODS: This was a retrospective review of adults undergoing ESBS at a tertiary academic center. Incidence of VTE in the 30-day postoperative period was recorded. Logistic regression analyses identified factors associated with VTE.RESULTS: 1122 ESBS cases between 2009 and 2019 were studied. Almost no cases (96.1%) employed perioperative VTE chemoprophylaxis. The overall incidence of VTE was 2.3% (26/1122). Malignant pathologies had a higher rate of VTE compared to nonmalignant pathologies (4.5% vs 2.0%, OR 2.85, 95%CI 1.22-6.66). Factors associated with an increased risk of VTE included a Caprini score greater than 5 (OR 1.53, 95% CI 1.28-1.83); multiple preoperative endocrinopathies such as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) (OR 22.48, 95% CI 3.93-128.70), adrenal insufficiency (OR 5.24, 95% CI 1.82-15.03), hypercortisolism (OR 4.46, 95% CI 1.47-13.56), and hypothyroidism (OR 3.69, 95% CI 1.66-8.20), each 10-hour increment of lumbar drain duration (OR 1.16, 95%CI 1.08-1.25), and each 10-hour increment for duration of hospitalization (OR 1.05, 95% CI 1.03-1.06).CONCLUSIONS: The incidence of VTE following ESBS is relatively low. Factors with a higher association with VTE include malignancy, preoperative endocrinopathies, higher Caprini score, prolonged lumbar drain duration, and prolonged hospitalization. Further study is needed to validate these findings and to refine clinical decision making around perioperative VTE prophylaxis. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22943

    View details for PubMedID 34894093

  • Comparison of endoscopic sinus surgery timing in lung transplant patients with cystic fibrosis. International forum of allergy & rhinology Johnson, J. R., Hwang, P. H., Nayak, J. V., Patel, Z. M. 2021

    Abstract

    BACKGROUND: No studies have investigated when endoscopic sinus surgery (ESS) is best performed in lung transplant patients with cystic fibrosis (CF). We sought to examine the effects of ESS timing on pulmonary health in this population.METHODS: A retrospective review of all adult lung transplant patients with CF who underwent ESS at our academic medical center over a near 25-year period was performed. Patients were split into two groups based on median time from lung transplantation to ESS. Twenty-three patients were included (12 ESS early and 11 ESS delayed). Outcomes included changes in pulmonary function tests (PFTs) from baseline, pre-operative to post-operative measurements, the number and duration of hospitalizations for pulmonary exacerbations, and the number of antibiotic courses used specifically to treat pulmonary exacerbations during the 12 months before and after ESS.RESULTS: Baseline demographics, operative history, and pulmonary function characteristics were similar between groups. While the ESS early group saw significant improvement from pre-operative percent predicted FEV1 (ppFEV1 ) at 12 months post-operatively (CI: 0.729 - 11.452, P=0.030), there were no significant post-operative PFT changes for the ESS delayed group. Post-operative improvement in FEV1 and ppFEV1 at 12 months was significantly higher for the ESS early group relative to the ESS delayed group (CI: 0.010 - 0.583, P=0.043; CI: 1.240 - 16.692, P=0.025; respectively). The ESS early group had a significant reduction in the need for total antibiotic courses compared to the ESS delayed group (ESS early median: -1, IQR: -1.5 to -0.5vs ESS delayed median: 0, IQR: 0 to 0; P=0.027).CONCLUSION: Earlier ESS interventions following lung transplantation may improve pulmonary function and attenuate pulmonary exacerbations in CF patients. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22935

    View details for PubMedID 34875144

  • Inflammatory molecular endotypes of nasal polyps derived from Caucasian and Japanese populations. The Journal of allergy and clinical immunology Nakayama, T., Lee, I. T., Le, W., Tsunemi, Y., Borchard, N. A., Zarabanda, D., Dholakia, S. S., Gall, P. A., Yang, A., Kim, D., Akutsu, M., Kashiwagi, T., Patel, Z. M., Hwang, P. H., Frank, D. N., Haruna, S., Ramakrishnan, V. R., Nolan, G. P., Jiang, S., Nayak, J. V. 2021

    Abstract

    BACKGROUND: Emerging evidence suggests that chronic rhinosinusitis with nasal polyps (CRSwNP) is a highly heterogeneous disease with disparate inflammatory characteristics between different racial groups and geographies. Little is known currently about possible distinguishing factors underlying these inflammatory differences.OBJECTIVE: To interrogate for differences between Caucasian and Japanese CRSwNP disease using whole transcriptome and single-cell RNA gene expression profiling of nasal polyps (NPs).METHODS: We performed whole transcriptome RNA sequencing (RNA-seq) with endotype stratification of NPs from 8 Caucasian (residing in USA) and 9 Japanese (residing in Japan) patients. Reproducibility was confirmed by qPCR in an independent validation set of 46 Caucasian and 31 Japanese patients. Single-cell RNA-seq stratified key cell types for contributory transcriptional signatures.RESULTS: Unsupervised clustering analysis identified two major endotypes present within both NP cohorts, which have previously been reported at the cytokine level: 1) type 2 endotype and 2) non-type 2 endotype. Importantly, there was a statistically significant difference in the proportion of these endotypes between these geographically distinct NP subgroups (p = 0.03). Droplet-based single-cell RNA sequencing further identified prominent type 2 inflammatory transcript expression: C-C motif chemokine ligand 13 (CCL13) and CCL18 in M2 macrophages, as well as cystatin SN (CST1) and CCL26 in basal, suprabasal, and secretory epithelial cells.CONCLUSION: NPs from both racial groups harbor the same two major endotypes, which we determine are present in differing ratios between each cohort with CRSwNP disease. Distinct inflammatory and epithelial cells contribute to the type 2 inflammatory profiles observed.

    View details for DOI 10.1016/j.jaci.2021.11.017

    View details for PubMedID 34863854

  • The Effect of Povidone-Iodine Nasal Spray on COVID-19 Nasopharyngeal Viral Load in Patients: A Randomized Control Trial. The Laryngoscope Zarabanda, D., Vukkadala, N., Phillips, K. M., Qian, Z. J., Mfuh, K. O., Hatter, M., Lee, I. T., Rao, V. K., Hwang, P. H., Domb, G., Patel, Z. M., Pinsky, B. A., Nayak, J. V. 2021

    Abstract

    OBJECTIVES: To determine the effect of povidone-iodine (PVP-I) nasal sprays on nasopharyngeal (NP) viral load as assessed by cycle threshold on quantitative polymerase chain reaction (qPCR) of SARS-CoV-2 in outpatients.STUDY DESIGN: Three arm, triple blinded, randomized, placebo-controlled clinical trial.METHODS: Participants were randomized within 5days of testing positive for COVID-19 to receive nasal sprays containing either placebo (0.9% saline), 0.5% PVP-I, or 2.0% PVP-I. NP swabs for qPCR analysis were taken at baseline, 1-hour post-PVP-I spray (2 sprays/nostril), and 3days post-PVP-I spray (20 sprays/nostril). Symptom and adverse event questionnaires were completed at baseline, day 3, and day 5. University of Pennsylvania Smell Identification Tests (UPSIT) were completed at baseline and day 30.RESULTS: Mean cycle threshold (Ct) values increased over time in all groups, indicating declining viral loads, with no statistically significant difference noted in the rate of change between placebo and PVP-I groups. 2.0% PVP-I group showed statistically significant improvement in all symptom categories, however also reported a high rate of nasal burning. Olfaction via UPSIT showed improvement by at least one category in all groups. There were no hospitalizations or mortalities within 30days of study enrollment.CONCLUSION: Saline and low concentration PVP-I nasal sprays are well tolerated. Similar reductions in SARS-CoV-2 nasopharyngeal viral load were seen over time in all groups. All treatment groups showed improvement in olfaction over 30days. These data suggest that dilute versions of PVP-I nasal spray are safe for topical use in the nasal cavity, but that PVP-I does not demonstrate virucidal activity in COVID-19 positive outpatients. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/lary.29935

    View details for PubMedID 34724213

  • Determinants of SARS-CoV-2 entry and replication in airway mucosal tissue and susceptibility in smokers. Cell reports. Medicine Nakayama, T., Lee, I. T., Jiang, S., Matter, M. S., Yan, C. H., Overdevest, J. B., Wu, C., Goltsev, Y., Shih, L., Liao, C., Zhu, B., Bai, Y., Lidsky, P., Xiao, Y., Zarabanda, D., Yang, A., Easwaran, M., Schurch, C. M., Chu, P., Chen, H., Stalder, A. K., McIlwain, D. R., Borchard, N. A., Gall, P. A., Dholakia, S. S., Le, W., Xu, L., Tai, C., Yeh, T., Erickson-Direnzo, E., Duran, J. M., Mertz, K. D., Hwang, P. H., Haslbauer, J. D., Jackson, P. K., Menter, T., Andino, R., Canoll, P. D., DeConde, A. S., Patel, Z. M., Tzankov, A., Nolan, G. P., Nayak, J. V. 2021: 100421

    Abstract

    Understanding viral tropism is an essential step towards reducing SARS-CoV-2 transmission, decreasing mortality from COVID-19, and limiting opportunities for mutant strains to arise. Currently, little is known about the extent to which distinct tissue sites in the human head & neck region and proximal respiratory tract selectively permit SARS-CoV-2 infection and replication. In this translational study, we discover key variabilities in the expression of ACE2 and TMPRSS2, essential SARS-CoV-2 entry factors, among the mucosal tissues of the human proximal airways. We show that SARS-CoV-2 infection is present in all examined head & neck tissues, with a notable tropism for the nasal cavity and tracheal mucosa. Finally, we uncover an association between smoking and higher SARS-CoV-2 viral infection in the human proximal airway, which may explain the increased susceptibility of smokers to developing severe COVID-19. This is at least partially explained by differences in IFN-beta1 levels between smokers and non-smokers.

    View details for DOI 10.1016/j.xcrm.2021.100421

    View details for PubMedID 34604819

  • 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

    Abstract

    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: ClinicalTrials.gov Identifier: NCT03783702.

    View details for DOI 10.1001/jamaoto.2021.1839

    View details for PubMedID 34351376

  • Deep learning automated segmentation of middle skull-base structures for enhanced navigation. International forum of allergy & rhinology Neves, C. A., Tran, E. D., Blevins, N. H., Hwang, P. H. 2021

    View details for DOI 10.1002/alr.22856

    View details for PubMedID 34185969

  • Surgical approach is associated with complication rate in sinonasal malignancy: A multicenter study. International forum of allergy & rhinology Beswick, D. M., Hwang, P. H., Adappa, N. D., Le, C. H., Humphreys DO, I. M., Getz, A. E., Suh, J. D., Aasen, D. M., Abuzeid, W. M., Chang, E. H., Kaizer, A. M., Kindgom, T. T., Kohanski, M. A., Nabavizadeh, S. A., Nayak, J. V., Palmer, J. N., Patel, Z. M., Ramakrishnan, V. R., Snyderman, C. H., St John, M. A., Wild, J., Wang, E. W. 2021

    Abstract

    BACKGROUND: Management of sinonasal malignancy (SNM) often includes surgical resection as part of the multimodality treatment. Treatment-related surgical morbidity can occur, yet risk factors associated with complications in this population have not been sufficiently investigated.METHODS: Adult patients with histologically confirmed SNM whose primary treatment included surgical resection were prospectively enrolled into an observational, multi-institutional cohort study from 2015 to 2020. Sociodemographic, disease, and treatment data were collected. Complications assessed included cerebrospinal fluid leak, orbital injury, intracranial injury, diplopia, meningitis, osteoradionecrosis, hospitalization for neutropenia, and subsequent chronic rhinosinusitis. The surgical approach was categorized as endoscopic resection (ER) or open/combined resection (O/CR). Associations between factors and complications were analyzed using Student's t test, Fisher's exact test, and logistic regression modeling.RESULTS: Overall, 142 patients met the inclusion criteria. Twenty-three subjects had at least 1 complication (16.2%). On unadjusted analysis, adjuvant radiation therapy was associated with developing a complication (91.3% vs 65.5%, p = 0.013). Compared with the ER group (n = 98), the O/CR group (n = 44) had a greater percentage of higher T-stage lesions (p = 0.004) and more frequently received adjuvant radiation (84.1% vs 64.4%, p = 0.017) and chemotherapy (50.0% vs 30.6%, p = 0.038). Complication rates were similar between the ER and O/CR groups without controlling for other factors. Regression analysis that retained certain factors showed O/CR was associated with increased odds of experiencing a complication (odds ratio, 3.34; 95% confidence interval, 1.06-11.19).CONCLUSIONS: Prospective, multicenter evaluation of SNM treatment outcomes is feasible. Undergoing O/CR was associated with increased odds of developing a complication after accounting for radiation therapy. Further studies are warranted to build upon these findings.

    View details for DOI 10.1002/alr.22833

    View details for PubMedID 34176231

  • Challenging our assumptions: oral corticosteroids and chronic rhinosinusitis without nasal polyposis. International forum of allergy & rhinology Chang, M. T., Hwang, P. H. 2021

    View details for DOI 10.1002/alr.22817

    View details for PubMedID 34057289

  • Olfactory Dysfunction in Patients Infected with 2019 Novel Coronavirus. Iranian journal of otorhinolaryngology Bakhshaee, M., Barzegar-Amini, M., Motedayen, Z., Khojasteh-Taheri, R., Rafiee, M., Amini, M., Layegh, P., Hashemzadeh, K., Omidvar, D., Hwang, P. H., Hosseinpoor, M. 2021; 33 (116): 163-171

    Abstract

    Introduction: The current study aimed at investigating the occurrence and features of olfactory dysfunction in patients with confirmed coronavirus disease 2019 (COVID-19) infection.Materials and Methods: Patients with laboratory and clinically confirmed COVID-19 infection were enrolled in this longitudinal study. They were managed in either the inpatient or outpatient setting. The demographic, clinical, and outcome data were retrieved from patients' medical records. Olfactory dysfunction features, including the onset pattern, duration, and recovery time were investigated. The visual analog scale (VAS) was utilized as a self-rating subjective measurement of olfactory function.Results: According to the results, the mean age of the patients (n=502) was obtained at 46.8±18.5 years; moreover, 52.4% and 47.6% of cases were female and male, respectively. It was also revealed that 35.4% and 64.5% of the subjects were outpatients and hospitalized, respectively. Based on the findings, 178 (38.4%) subjects had olfactory dysfunction. The mean values of VAS in hyposmic patients were estimated at 2.5±2.5, 8.3 ±2.1, and 9.4±1.6 at the first evaluation, in 2 weeks, and after 1 month of follow-up (P<0.001). The onset of olfactory dysfunction was more suddenly (58.7%). The majority of cases experienced olfactory dysfunction at the same time as other symptoms 72(51.1%). Based on the results, 0.4% of subjects infected with COVID-19 had olfactory dysfunction as an isolated symptom. The olfactory dysfunction was recovered after 2 weeks in 18 (25.3%) anosmic and 37(46.8%) hyposmic patients.Conclusion: Olfactory dysfunction seemed to be an important symptom of COVID-19 infection. The occurrence of this disturbance as a transient self-limited condition was significantly higher among female subjects.

    View details for DOI 10.22038/ijorl.2021.51614.2750

    View details for PubMedID 34222108

  • Multi-compartment skull base orbital cavernous venous malformation: A rare presentation of a common orbital mass. American journal of ophthalmology case reports Azad, A. D., Sears, C. M., Hwang, P. H., Mohyeldin, A., Fernandez-Miranda, J., Kossler, A. L. 2021; 21: 101020

    Abstract

    Purpose: We present a unique case of an orbital intraconal cavernous venous malformation that extended along the trigeminal nerve to the pterygopalatine and middle cranial fossa. Our aim is to describe an atypical presentation of this common orbital vascular mass.Observations: A 57-year-old female presented with right eye proptosis. Orbital magnetic resonance imaging demonstrated a lobulated contrast-enhancing mass involving the right intraconal orbital space, pterygopalatine fossa, and right middle cranial fossa, radiographically presumed to be a schwannoma. Intraoperative and histopathologic evaluation confirmed a cavernous venous malformation that extended along the trigeminal nerve. The mass, including its attachments to the cranial nerves and dura, was successfully removed via a combined transorbital and endoscopic endonasal approach. The patient recovered well with 20/20 vision, full extraocular movements, and resolution of proptosis.Conclusions: This a rare presentation of an orbital cavernous venous malformation not previously described. Cavernous venous malformations typically present as ovoid well-circumscribed lesions; however, they can also extend outside the orbit along the path of cranial nerves, as was observed in this case. These types of lesions should be included in the differential diagnosis of masses arising from or extending along cranial nerves, even when involving the orbit.

    View details for DOI 10.1016/j.ajoc.2021.101020

    View details for PubMedID 33598587

  • 5-year outcomes of salvage endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma. Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale Thamboo, A., Patel, V. S., Hwang, P. H. 2021; 50 (1): 12

    Abstract

    OBJECTIVE: Recurrent nasopharyngeal carcinoma (rNPC) can be salvaged with re-irradiation, open nasopharyngectomy, and more recently endoscopic nasopharyngectomy. However, long-term outcomes of endoscopic approaches are lacking. Thus, we report 5-year outcomes following endoscopic nasopharyngectomy for rNPC.METHODS: Patients who underwent endoscopic nasopharyngectomy for rNPC between January 2000 and January 2012 were retrospectively reviewed. Patients were included if they had their first endoscopic nasopharyngectomy at least 5years prior to this study. Presenting (cTNM) status and recurrent (rTNM) status for each recurrence was determined. Outcomes included margin status, disease recurrence, death, and complication rates.RESULTS: Thirteen patients were included. Four patients had a prior open nasopharyngectomy. Mean time follow-up was 74.3months (range=56.4-96months). Negative margins were achieved in 77% of initial cases. Positive margins were associated with higher rT stages. Re-recurrence was seen in 6 patients, which was also associated with a higher cStage and rStage. All patients with positive margins had re-recurrence. Four patients required repeat endoscopic nasopharyngectomy and two received chemoradiation. All four with a second endoscopic procedure had further disease recurrence. Five-year local disease-free and overall survival rates were 53.9 and 84.6%, respectively. The minor complication rate was 52.6%, major operative complication rate was 0.0%, and late complication rate was 23.1%.CONCLUSION: Endoscopic nasopharyngectomy demonstrates promising 5-year overall survival rate for rT1 and rT2 cases of rNPC with favorable complication rates. Lower rStages were associated with a higher disease-free rate, and lower cStages were associated with improved overall prognosis. Close surveillance and prompt management of recurrences can be associated with favorable long-term tumor control.LEVEL OF EVIDENCE: 4.

    View details for DOI 10.1186/s40463-020-00482-x

    View details for PubMedID 33597031

  • Somatostatin receptor 2 expression in nasopharyngeal cancer is induced by Epstein Barr virus infection: impact on prognosis, imaging and therapy. Nature communications Lechner, M., Schartinger, V. H., Steele, C. D., Nei, W. L., Ooft, M. L., Schreiber, L., Pipinikas, C. P., Chung, G. T., Chan, Y. Y., Wu, F., To, K., Tsang, C. M., Pearce, W., Morelli, D., Philpott, M., Masterson, L., Nibhani, R., Wells, G., Bell, C. G., Koller, J., Delecluse, S., Yip, Y. L., Liu, J., Forde, C. T., Forster, M. D., Jay, A., Dudas, J., Krapp, A., Wan, S., Uprimny, C., Sprung, S., Haybaeck, J., Fenton, T. R., Chester, K., Thirlwell, C., Royle, G., Marafioti, T., Gupta, R., Indrasari, S. R., Herdini, C., Slim, M. A., Indrawati, I., Sutton, L., Fles, R., Tan, B., Yeong, J., Jain, A., Han, S., Wang, H., Loke, K. S., He, W., Xu, R., Jin, H., Cheng, Z., Howard, D., Hwang, P. H., Le, Q., Tay, J. K., West, R. B., Tsao, S. W., Meyer, T., Riechelmann, H., Oppermann, U., Delecluse, H., Willems, S. M., Chua, M. L., Busson, P., Lo, K. W., Wollmann, G., Pillay, N., Vanhaesebroeck, B., Lund, V. J. 2021; 12 (1): 117

    Abstract

    Nasopharyngeal cancer (NPC), endemic in Southeast Asia, lacks effective diagnostic and therapeutic strategies. Even in high-income countries the 5-year survival rate for stage IV NPC is less than 40%. Here we report high somatostatin receptor 2 (SSTR2) expression in multiple clinical cohorts comprising 402 primary, locally recurrent and metastatic NPCs. We show that SSTR2 expression is induced by the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) via the NF-kappaB pathway. Using cell-based and preclinical rodent models, we demonstrate the therapeutic potential of SSTR2 targeting using a cytotoxic drug conjugate, PEN-221, which is found to be superior to FDA-approved SSTR2-binding cytostatic agents. Furthermore, we reveal significant correlation of SSTR expression with increased rates of survival and report in vivo uptake of the SSTR2-binding 68Ga-DOTA-peptide radioconjugate in PET-CT scanning in a clinical trial of NPC patients (NCT03670342). These findings reveal a key role in EBV-associated NPC for SSTR2 in infection, imaging, targeted therapy and survival.

    View details for DOI 10.1038/s41467-020-20308-8

    View details for PubMedID 33402692

  • Sinonasal Ewing sarcoma misdiagnosed as recurrent glomangiopericytoma: Case report and literature review Otolaryngology Case Reports Huang, A. E., Hwang, P. H., Lin, J. H., Chang, M. T. 2021; 21: 100369
  • Resonant vibration of the sinonasal cavities for the treatment of nasal congestion. International forum of allergy & rhinology Khanwalkar, A., Johnson, J., Zhu, W., Johnson, E., Lin, B., Hwang, P. H. 2021

    View details for DOI 10.1002/alr.22877

    View details for PubMedID 34355851

  • 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

    Abstract

    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 considered.ClinicalTrials.gov Identifier: NCT02748070.

    View details for DOI 10.1001/jamaoto.2021.0011

    View details for PubMedID 33662124

  • International Consensus Statement on Rhinology and Allergy: Rhinosinusitis. International forum of allergy & rhinology Orlandi, R. R., Kingdom, T. T., Smith, T. L., Bleier, B., DeConde, A., Luong, A., Poetker, D. M., Soler, Z., Welch, K. C., Wise, S. K., Adappa, N., Alt, J. A., Anselmo-Lima, W. T., Bachert, C., Baroody, F. M., Batra, P. S., Bernal-Sprekelsen, M., Beswick, D., Bhattacharyya, N., Chandra, R. K., Chang, E., Chiu, A., Chowdhury, N., Citardi, M. J., Cohen, N. A., Conley, D. B., DelGaudio, J., Desrosiers, M., Douglas, R., Eloy, J. A., Fokkens, W. J., Gray, S. T., Gudis, D. A., Hamilos, D. L., Han, J. K., Harvey, R., Hellings, P., Holbrook, E. H., Hopkins, C., Hwang, P., Javer, A. R., Jiang, R., Kennedy, D., Kern, R., Laidlaw, T., Lal, D., Lane, A., Lee, H., Lee, J. T., Levy, J. M., Lin, S. Y., Lund, V., McMains, K. C., Metson, R., Mullol, J., Naclerio, R., Oakley, G., Otori, N., Palmer, J. N., Parikh, S. R., Passali, D., Patel, Z., Peters, A., Philpott, C., Psaltis, A. J., Ramakrishnan, V. R., Ramanathan, M. J., Roh, H., Rudmik, L., Sacks, R., Schlosser, R. J., Sedaghat, A. R., Senior, B. A., Sindwani, R., Smith, K., Snidvongs, K., Stewart, M., Suh, J., Tan, B. K., Turner, J. H., van Drunen, C. M., Voegels, R., Wang, D. Y., Woodworth, B. A., Wormald, P., Wright, E. D., Yan, C., Zhang, L., Zhou, B. 2020

    Abstract

    BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.METHODS: ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.RESULTS: ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.CONCLUSION: This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22741

    View details for PubMedID 33236525

  • ACE2 localizes to the respiratory cilia and is not increased by ACE inhibitors or ARBs. Nature communications Lee, I. T., Nakayama, T., Wu, C., Goltsev, Y., Jiang, S., Gall, P. A., Liao, C., Shih, L., Schurch, C. M., McIlwain, D. R., Chu, P., Borchard, N. A., Zarabanda, D., Dholakia, S. S., Yang, A., Kim, D., Chen, H., Kanie, T., Lin, C., Tsai, M., Phillips, K. M., Kim, R., Overdevest, J. B., Tyler, M. A., Yan, C. H., Lin, C., Lin, Y., Bau, D., Tsay, G. J., Patel, Z. M., Tsou, Y., Tzankov, A., Matter, M. S., Tai, C., Yeh, T., Hwang, P. H., Nolan, G. P., Nayak, J. V., Jackson, P. K. 2020; 11 (1): 5453

    Abstract

    The coronavirus SARS-CoV-2 is the causative agent of the ongoing severe acute respiratory disease pandemic COVID-19. Tissue and cellular tropism is one key to understanding the pathogenesis of SARS-CoV-2. We investigate the expression and subcellular localization of the SARS-CoV-2 receptor, angiotensin-converting enzyme 2 (ACE2), within the upper (nasal) and lower (pulmonary) respiratory tracts of human donors using a diverse panel of banked tissues. Here, we report our discovery that the ACE2 receptor protein robustly localizes within the motile cilia of airway epithelial cells, which likely represents the initial or early subcellular site of SARS-CoV-2 viral entry during host respiratory transmission. We further determine whether ciliary ACE2 expression in the upper airway is influenced by patient demographics, clinical characteristics, comorbidities, or medication use, and show the first mechanistic evidence that the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) does not increase susceptibility to SARS-CoV-2 infection through enhancing the expression of ciliary ACE2 receptor. These findings are crucial to our understanding of the transmission of SARS-CoV-2 for prevention and control of this virulent pathogen.

    View details for DOI 10.1038/s41467-020-19145-6

    View details for PubMedID 33116139

  • Outcomes in Treatment of Rhinosinusitis in the Setting of Medication Induced Immunosuppression. American journal of rhinology & allergy Alapati, R., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2020: 1945892420947932

    Abstract

    BACKGROUND: There is no data currently available to direct nuanced treatment for recurrent acute and chronic rhinosinusitis (RARS, CRS) in patients on daily, long term medications that suppress the immune system.OBJECTIVE: This study sought to evaluate the outcomes of different treatment pathways when treating immunosuppressed patients with chronic rhinosinusitis or recurrent acute rhinosinusitis.METHODS: A retrospective review of patients on immune suppressing medication presenting to a tertiary care center with RARS or CRS between the years 2014-2019 was completed. Patients were categorized into three groups based on treatment: medical management alone (MM), surgery after medical management (SAMM), or upfront surgery (US). Lund-Kennedy scores (LKS) and SNOT-22 scores were evaluated at baseline, 1 month, 3 months and 6 months from presentation.RESULTS: 68 patients met inclusion criteria, with no difference in demographics between groups. Patients who were treated with US and SAMM had significantly higher baseline LKS than those who were treated with MM alone (p=0.050, p=0.039). Once this difference was controlled for, there was no significant difference in overall change of LKS between the three groups over time. There was no significant disparity in baseline SNOT-22 scores between the three groups, but patients who underwent US had a significantly higher improvement in SNOT-22 from baseline compared to those undergoing MM alone (p=0.013).CONCLUSION: Patients experiencing chronic rhinosinusitis and recurrent acute rhinosinusitis who are taking immunosuppressive medication can significantly improve from both medical and surgical management, but upfront surgical management appears to result in greater disease resolution relative to medical management in those with CRS. More study is needed in the RARS patient population regarding upfront surgery versus medical management.

    View details for DOI 10.1177/1945892420947932

    View details for PubMedID 32746611

  • In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic NEUROSURGERY Patel, Z. M., Fernandez-Miranda, J., Hwang, P. H., Nayak, J. V., Dodd, R. L., Sajjadi, H., Jackler, R. K. 2020; 87 (2): E162–E163
  • In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic. Neurosurgery Patel, Z. M., Fernandez-Miranda, J., Hwang, P. H., Nayak, J. V., Dodd, R. L., Sajjadi, H., Jackler, R. K. 2020

    View details for DOI 10.1093/neuros/nyaa156

    View details for PubMedID 32323725

  • Letter: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic. Neurosurgery Patel, Z. M., Fernandez-Miranda, J., Hwang, P. H., Nayak, J. V., Dodd, R., Sajjadi, H., Jackler, R. K. 2020

    View details for DOI 10.1093/neuros/nyaa125

    View details for PubMedID 32293678

  • A multi-institutional review of outcomes in biopsy-proven chronic invasive fungal sinusitis. International forum of allergy & rhinology Humphreys, I. M., Wandell, G. M., Miller, C., Rathor, A., Schmidt, R. A., Turner, J. H., Hwang, P. H., Davis, G. E. 2020

    Abstract

    BACKGROUND: Chronic invasive fungal sinusitis (CIFS) is a rare, life-threatening infection of the nose and sinuses. This study aims to identify factors that impact survival in 1 of the largest cohorts to date.METHODS: Pathology records were reviewed for biopsy-proven CIFS from 3 tertiary academic institutions from 1995 to 2016. Variables were analyzed using log-rank survival analysis. Univariate Cox regression was performed at 1 and 12 months.RESULTS: Thirty-eight patients were included. Hematologic malignancy and diabetes were the most common underlying diseases (32% each). Aspergillus was the most common fungus (63%). Greater than 75% of the patients had an absolute neutrophil count (ANC) >1000 at the time of diagnosis. Overall survival at 1, 6, and 12 months was 89%, 68%, and 48%, respectively. In univariate analysis, factors associated with worse survival included: ANC <500 at 12 months (hazard ratio [HR] 4.8; p = 0.01), ANC <1000 at 12 months (HR 5.8; p = 0.001), and recent chemotherapy (HR 4; p = 0.01). The following factor was associated with improved survival in univariate analysis: ANC as a linear variable in the entire cohort (HR 0.7; p = 0.005).CONCLUSION: We present a multi-institutional case-series of CIFS and long-term follow-up. ANC <1000 at time of diagnosis and recent chemotherapy (within 1 month of diagnosis) are associated with poorer survival, whereas a rising ANC >1000 is associated with improved survival at 12 months. Further prospective studies are needed to further define factors that affect outcomes.

    View details for DOI 10.1002/alr.22547

    View details for PubMedID 32282122

  • Endoscopic endonasal surgery for giant pediatric craniopharyngioma. Neurosurgical focus: Video Mohyeldin, A., Hwang, P., Grant, G. A., Fernandez-Miranda, J. C. 2020; 2 (2): V8

    Abstract

    Pediatric craniopharyngiomas that were once thought to be inoperable or considered only for salvage medical therapy are now being reconsidered for aggressive surgical resection via endoscopic endonasal approaches. Here we review the operative video case of an 11-year-old with a giant complex craniopharyngioma that was resected via an endoscopic endonasal approach. Due to the extent of tumor burden near the basilar apex, a transclival approach was necessary. To accomplish this, a wide sphenoidotomy, posterior ethmoidectomy, and resection of the middle turbinate were necessary to create enough working space for the resection. We also highlight several key innovations in pediatric endoscopic endonasal surgery management and underscore a multidisciplinary approach that allows for the safe and successful treatment of these lesions. Our multidisciplinary team involves an experienced fellowship-trained endoscopic skull base surgeon and otolaryngologist, as well as a pediatric neurosurgeon, pediatric endocrinologist, pediatric anesthesiologist, and pediatric intensivists who play important roles in the preoperative, intraoperative, and postoperative phases of care of the patient. Finally, we discuss critical surgical decision points including pituitary transposition, which has a lot of conceptual appeal when it is anatomically feasible but unfortunately, in our experience, has low functional preservation rates. Initially, we always aim to utilize pituitary transposition for tuberoinfundibular craniopharyngiomas, and once the relationship between the tumor and the stalk is determined, a decision on whether to preserve or sacrifice the stalk and pituitary gland is made. In this particular case, there was a salvageable stalk and the transposition was performed knowing that the chances for functional preservation were low. The video can be found here: https://youtu.be/ClL73FU5QIU.

    View details for DOI 10.3171/2020.4.FocusVid.19983

    View details for PubMedID 36284783

    View details for PubMedCentralID PMC9542483

  • Indications and Outcomes for Patients With Limited Symptoms Undergoing Endoscopic Sinus Surgery. American journal of rhinology & allergy Rahman, A. S., Hwang, P. H., Alapati, R., Lin, Y., Nayak, J. V., Patel, Z. M., Yan, C. H. 2020: 1945892420912159

    View details for DOI 10.1177/1945892420912159

    View details for PubMedID 32168996

  • 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

  • Effect of Omega-3 Supplementation in Patients With Smell Dysfunction Following Endoscopic Sellar and Parasellar Tumor Resection: A Multicenter Prospective Randomized Controlled Trial. Neurosurgery Yan, C. H., Rathor, A., Krook, K., Ma, Y., Rotella, M. R., Dodd, R. L., Hwang, P. H., Nayak, J. V., Oyesiku, N. M., DelGaudio, J. M., Levy, J. M., Wise, J., Wise, S. K., Patel, Z. M. 2020

    Abstract

    BACKGROUND: Endoscopic endonasal approaches pose the potential risk of olfactory loss. Loss of olfaction and potentially taste can be permanent and greatly affect patients' quality of life. Treatments for olfactory loss have had limited success. Omega-3 supplementation may be a therapeutic option with its effect on wound healing and nerve regeneration.OBJECTIVE: To evaluate the impact on olfaction in patients treated with omega-3 supplementation following endoscopic skull base tumor resection.METHODS: In this multi-institutional, prospective, randomized controlled trial, 110 patients with sellar or parasellar tumors undergoing endoscopic resection were randomized to nasal saline irrigations or nasal saline irrigations plus omega-3 supplementation. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and at 6 wk, 3 mo, and 6 mo postoperatively.RESULTS: Eighty-seven patients completed all 6 mo of follow-up (41 control arm, 46 omega-3 arm). At 6 wk postoperatively, 25% of patients in both groups experienced a clinically significant loss in olfaction. At 3 and 6 mo, patients receiving omega-3 demonstrated significantly less persistent olfactory loss compared to patients without supplementation (P=.02 and P=.01, respectively). After controlling for multiple confounding variables, omega-3 supplementation was found to be protective against olfactory loss (odds ratio [OR] 0.05, 95% CI 0.003-0.81, P=.03). Tumor functionality was a significant independent predictor for olfactory loss (OR 32.7, 95% CI 1.15-929.5, P=.04).CONCLUSION: Omega-3 supplementation appears to be protective for the olfactory system during the healing period in patients who undergo endoscopic resection of sellar and parasellar masses.

    View details for DOI 10.1093/neuros/nyz559

    View details for PubMedID 31950156

  • Hemodynamic changes in patients undergoing office-based sinus procedures under local anesthesia. International forum of allergy & rhinology Chang, M. T., Jitaroon, K. n., Nguyen, T. n., Yan, C. H., Overdevest, J. B., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2020; 10 (1): 114–20

    Abstract

    The objective of this study is to characterize changes in hemodynamics, pain, and anxiety during office-based endoscopic sinus procedures performed under local anesthesia.We conducted a prospective study of adults undergoing in-office endoscopic sinus procedures under local anesthesia. Patients with American Society of Anesthesiologists (ASA) Physical Status Classification System class 1 or 2 were included. Anesthesia was administered by topical 4% lidocaine/oxymetazoline and submucosal injection of 1% lidocaine/1:200,000 epinephrine. Vital signs and pain were measured at baseline, postinjection, and 5-minute intervals throughout the procedure. Anxiety levels were scored using the State-Trait Anxiety Inventory (STAI). Univariate and multivariate regression analyses were performed to identify factors significantly associated with changes in each hemodynamic metric.Twenty-five patients were studied. This cohort was 52% male, mean age of 57.8 ± 14.4 years, and Charlson Comorbidity Index (CCI) median of 2. Mean procedure duration was 25.0 ± 10.3 minutes. Mean maximal increase in systolic blood pressure (SBP) was 24.6 ± 17.8 mmHg from baseline. Mean maximal heart rate increase was 22.8 ± 10.8 beats per minute (bpm) from baseline. In multivariate regression analysis, when accounting for patient age, cardiac comorbidity, CCI, and ASA, older age was significantly associated with an increase of >20 mmHg in SBP (p = 0.043). Mean pain score during procedures was 1.5 ± 1.3 with a mean maximum of 4.0 ± 2.6. STAI anxiety scores did not change significantly from preprocedure to postprocedure (32.8 ± 11.6 to 31.0 ± 12.6, p = 0.46). No medical complications occurred.Although patients appear to tolerate office procedures well, providers should recognize the potential for significant fluctuations in blood pressure during the procedure, especially in older patients.

    View details for DOI 10.1002/alr.22460

    View details for PubMedID 31899857

  • Microbiotyping the Sinonasal Microbiome. Frontiers in cellular and infection microbiology Bassiouni, A., Paramasivan, S., Shiffer, A., Dillon, M. R., Cope, E. K., Cooksley, C., Ramezanpour, M., Moraitis, S., Ali, M. J., Bleier, B. S., Callejas, C., Cornet, M. E., Douglas, R. G., Dutra, D., Georgalas, C., Harvey, R. J., Hwang, P. H., Luong, A. U., Schlosser, R. J., Tantilipikorn, P., Tewfik, M. A., Vreugde, S., Wormald, P., Caporaso, J. G., Psaltis, A. J. 2020; 10: 137

    Abstract

    This study offers a novel description of the sinonasal microbiome, through an unsupervised machine learning approach combining dimensionality reduction and clustering. We apply our method to the International Sinonasal Microbiome Study (ISMS) dataset of 410 sinus swab samples. We propose three main sinonasal "microbiotypes" or "states": the first is Corynebacterium-dominated, the second is Staphylococcus-dominated, and the third dominated by the other core genera of the sinonasal microbiome (Streptococcus, Haemophilus, Moraxella, and Pseudomonas). The prevalence of the three microbiotypes studied did not differ between healthy and diseased sinuses, but differences in their distribution were evident based on geography. We also describe a potential reciprocal relationship between Corynebacterium species and Staphylococcus aureus, suggesting that a certain microbial equilibrium between various players is reached in the sinuses. We validate our approach by applying it to a separate 16S rRNA gene sequence dataset of 97 sinus swabs from a different patient cohort. Sinonasal microbiotyping may prove useful in reducing the complexity of describing sinonasal microbiota. It may drive future studies aimed at modeling microbial interactions in the sinuses and in doing so may facilitate the development of a tailored patient-specific approach to the treatment of sinus disease in the future.

    View details for DOI 10.3389/fcimb.2020.00137

    View details for PubMedID 32322561

  • Robust ACE2 protein expression localizes to the motile cilia of the respiratory tract epithelia and is not increased by ACE inhibitors or angiotensin receptor blockers. medRxiv : the preprint server for health sciences Lee, I. T., Nakayama, T. n., Wu, C. T., Goltsev, Y. n., Jiang, S. n., Gall, P. A., Liao, C. K., Shih, L. C., Schürch, C. M., McIlwain, D. R., Chu, P. n., Borchard, N. A., Zarabanda, D. n., Dholakia, S. S., Yang, A. n., Kim, D. n., Kanie, T. n., Lin, C. D., Tsai, M. H., Phillips, K. M., Kim, R. n., Overdevest, J. B., Tyler, M. A., Yan, C. H., Lin, C. F., Lin, Y. T., Bau, D. T., Tsay, G. J., Patel, Z. M., Tsou, Y. A., Tai, C. J., Yeh, T. H., Hwang, P. H., Nolan, G. P., Nayak, J. V., Jackson, P. K. 2020

    Abstract

    We investigated the expression and subcellular localization of the SARS-CoV-2 receptor, angiotensin-converting enzyme 2 (ACE2), within the upper (nasal) and lower (pulmonary) respiratory tracts of healthy human donors. We detected ACE2 protein expression within the cilia organelle of ciliated airway epithelial cells, which likely represents the initial or early subcellular site of SARS-CoV-2 viral entry during respiratory transmission. We further determined whether ACE2 expression in the cilia of upper respiratory cells was influenced by patient demographics, clinical characteristics, co-morbidities, or medication use, and found no evidence that the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) increases ACE2 protein expression.

    View details for DOI 10.1101/2020.05.08.20092866

    View details for PubMedID 32511516

    View details for PubMedCentralID PMC7273284

  • The international sinonasal microbiome study (ISMS): a multi-centre, multi-national characterization of sinonasal bacterial ecology. Allergy Paramasivan, S. n., Bassiouni, A. n., Shiffer, A. n., Dillon, M. R., Cope, E. K., Cooksley, C. n., Ramezanpour, M. n., Moraitis, S. n., Ali, M. J., Bleier, B. n., Callejas, C. n., Cornet, M. E., Douglas, R. G., Dutra, D. n., Georgalas, C. n., Harvey, R. J., Hwang, P. H., Luong, A. U., Schlosser, R. J., Tantilipikorn, P. n., Tewfik, M. A., Vreugde, S. n., Wormald, P. J., Caporaso, J. G., Psaltis, A. J. 2020

    Abstract

    The sinonasal microbiome remains poorly defined, with our current knowledge based on a few cohort studies whose findings are inconsistent. Furthermore, the variability of the sinus microbiome across geographical divides remains unexplored. We characterise the sinonasal microbiome and its geographical variations in both health and disease using 16S rRNA gene sequencing of 410 individuals from across the world. Although the sinus microbial ecology is highly variable between individuals, we identify a core microbiome comprised of Corynebacterium, Staphylococcus, Streptococcus, Haemophilus, and Moraxella species in both healthy and chronic rhinosinusitis (CRS) cohorts. Corynebacterium (mean relative abundance = 44.02%) and Staphylococcus (mean relative abundance = 27.34%) appear particularly dominant in the majority of patients sampled. Amongst patients suffering from CRS with nasal polyps, a statistically significant reduction in relative abundance of Corynebacterium (40.29% vs 50.43%; p = 0.02) was identified. Despite some measured differences in microbiome composition and diversity between some of the participating centres in our cohort, these differences would not alter the general pattern of core organisms described. Nevertheless, atypical or unusual organisms reported in short-read amplicon sequencing studies and that are not part of the core microbiome should be interpreted with caution. The delineation of the sinonasal microbiome and standardised methodology described within our study will enable further characterisation and translational application of the sinus microbiota.

    View details for DOI 10.1111/all.14276

    View details for PubMedID 32167574

  • The Effect of Endoscopic Sinus Surgery on Eustachian Tube Dysfunction Symptoms. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Chang, M. T., Hosseini, D. K., Song, S. H., Nayak, J. V., Patel, Z. M., Lee, J. Y., Hwang, P. H. 2020: 194599820917396

    Abstract

    We assessed how eustachian tube dysfunction (ETD) changed with endoscopic sinus surgery (ESS) and identified factors associated with improvement.Retrospective chart review.Academic center.Patients undergoing ESS for chronic rhinosinusitis with and without nasal polyposis (CRSwNP, CRSsNP) or recurrent acute rhinosinusitis (RARS) completed the Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. Included in analyses were demographics, comorbidities, Sinonasal Outcome Test 22 (SNOT-22), radiographic score, endoscopy score, procedure, and medication use. Regression analysis identified factors associated with improvement, defined as ΔETDQ-7 >3.5.In total, 302 patients were studied. ETD prevalence was 68% in CRSsNP, 48% in CRSwNP, and 88% in RARS. Patients with ETD had a mean baseline ETDQ-7 of 25.8 ± 8.0 and improved postoperatively at 2 weeks (19.9 ± 8.1, P < .001), 6 weeks (17.8 ± 9.3, P < .001), 3 months (16.8 ± 8.5, P < .001), and 6 months (16.4 ± 7.9, P < .001). At 6 months, ETD improved in 89% of patients with CRSsNP, 68% with CRSwNP, and 78% with RARS. On multivariate analysis, ETD improvement was associated with higher preoperative ETDQ-7 score (adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 1.04-1.22; P = .030), higher preoperative SNOT-22 score (aOR, 1.02; 95% CI, 1.02-1.08; P = .001), higher preoperative SNOT-22 ear subscore (aOR, 1.27; 95% CI, 1.02-1.65; P = .034), posterior ethmoidectomy (aOR, 1.59; 95% CI, 1.22-4.92; P = .025), and postoperative corticosteroid spray use (aOR, 1.57; 95% CI, 1.17-1.66; P = .008).ETD symptoms often improve following ESS. Factors associated with improvement include higher preoperative disease burden, posterior ethmoidectomy, and postoperative corticosteroid spray.4.

    View details for DOI 10.1177/0194599820917396

    View details for PubMedID 32343633

  • Application of holographic augmented reality for external approaches to the frontal sinus. International forum of allergy & rhinology Neves, C. A., Vaisbuch, Y. n., Leuze, C. n., McNab, J. A., Daniel, B. n., Blevins, N. H., Hwang, P. H. 2020

    Abstract

    External approaches to the frontal sinus such as osteoplastic flaps are challenging because they require blind entry into the sinus, posing risks of injury to the brain or orbit. Intraoperative computed tomography (CT)-based navigation is the current standard for planning the approach, but still necessitates blind entry into the sinus. The aim of this work was to describe a novel technique for external approaches to the frontal sinus using a holographic augmented reality (AR) application.Our team developed an AR system to create a 3-dimensional (3D) hologram of key anatomical structures, based on CT scans images. Using Magic Leap AR goggles for visualization, the frontal sinus hologram was aligned to the surface anatomy in 6 fresh cadaveric heads' anatomic boundaries, and the boundaries of the frontal sinus were demarcated based on the margins of the fused image. Trephinations and osteoplastic flap approaches were performed. The specimens were re-scanned to assess the accuracy of the osteotomy with respect to the actual frontal sinus perimeter.Registration and surgery were completed successfully in all specimens. Registration required an average of 2 minutes. The postprocedure CT showed a mean difference of 1.4 ± 4.1 mm between the contour of the osteotomy and the contour of the frontal sinus. One surgical complication (posterior table perforation) occurred (16%).We describe proof of concept of a novel technique utilizing AR to enhance external approaches to the frontal sinus. Holographic AR-enhanced surgical navigation holds promise for enhanced visualization of target structures during surgical approaches to the sinuses.

    View details for DOI 10.1002/alr.22546

    View details for PubMedID 32362076

  • 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

    Abstract

    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

  • Endoscopic Endonasal Surgery for Resection of Giant Craniopharyngioma in a Toddler-Multimodal Presurgical Planning, Surgical Technique, and Management of Complications: 2-Dimensional Operative Video. Operative neurosurgery (Hagerstown, Md.) Fernandez-Miranda, J. C., Hwang, P., Grant, G. 2019

    Abstract

    A 2-yr-old patient with a giant craniopharyngioma presented with seizures and panhypopituitarism. The lesion was initially approached at an outside institution with a transfrontal cyst fenestration, but progressive growth occurred later. Multiple management options were considered; we recommended an endoscopic endonasal approach with the goal of maximal safe resection. Virtual reality simulation and 3-dimensional printing were employed to evaluate whether the absence of pneumatization of the sinuses and the overall size of the nasal cavity could preclude effective surgical access. Our lab results suggested the binostril approach was feasible. A wide surgical exposure was performed from planum sphenoidale to clivus and from orbit to orbit. After removing the large calcified tumor portion, we found an accurate plane of dissection between tumor capsule, hypothalami, and visual pathways. By the end of resection, arterial bleeding was encountered secondary to an avulsion of the posterior communicating artery from the posterior cerebral artery. An angled aneurysm clip was placed with a single-shaft applier to secure the site of injury without narrowing the parent artery. Immediate and delayed magnetic resonance imaging and computed tomography angiography studies showed gross total resection, no stroke, and no pseudoaneurysm formation. On postoperative day 9, patient developed neurological decline and pneumocephalus secondary to necrotic nasoseptal flap. Two endonasal repairs with a lateral nasal wall flap were attempted with no success. A temporoparietal fascia flap was then harvested and transposed from the temporal to the pterygopalatine fossa to successfully repair the skull base defect. The patient has made an extraordinary recovery with no neurological sequalae. The patient's parents provided consent for the procedure and use of intraoperative photos and videos for academic purposes. Institutional Review Board approval was not required.

    View details for DOI 10.1093/ons/opz384

    View details for PubMedID 31814025

  • Clinical characteristics and prognostic factors of malignant tumors involving pterygopalatine fossa. Head & neck Woo, H., Hwang, P. H., Kaplan, M. J., Choby, G. 2019

    Abstract

    BACKGROUND: To identify the clinical characteristics and prognostic factors of malignancies involving the pterygopalatine fossa (PPF).METHODS: Fifty-seven patients who underwent curative surgery for malignant tumor involving PPF were reviewed.RESULTS: The rates for three-year local control (LC), five-year disease-free survival (DFS) and five-year overall survival (OS) were 55.4%, 34.5%, and 52.7%, respectively. Perineural invasion (PNI) of the maxillary nerve with facial numbness (symptomatic V2 PNI) (P = .04) and cranial involvement (P = .03) were predictors for poor OS. Symptomatic V2 PNI was also a significant predictor for poor LC (P = .05) and DFS (P = .03). Within the subgroup analysis of patients with pathologically confirmed V2 PNI, asymptomatic V2 PNI patients had significantly better LC (71.2% vs 31.8%, P = .05) and DFS (43.8% vs 17.3%, P = .05) compared to symptomatic patients.CONCLUSION: Malignant tumors involving the PPF have diverse pathologies and a poor prognosis. Symptomatic V2 PNI may be an independent poor prognostic factor.

    View details for DOI 10.1002/hed.26000

    View details for PubMedID 31682306

  • 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

    Abstract

    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

  • Neutrophil Extracellular Traps Induce Tissue-Invasive Macrophages in Granulomatosis with Polyangiitis Dominated by Ear, Nose and Throat Manifestations Akiyama, M., Ibrahim, N., Zeisbrich, M., Hwang, P., Goronzy, J., Weyand, C. WILEY. 2019
  • Endoscopic endonasal approach for resection of pediatric chordoma with brainstem invasion. Neurosurgical focus: Video Abhinav, K., Hong, D., Yan, C. H., Hwang, P., Fernandez-Miranda, J. C. 2019; 1 (2): V20

    Abstract

    A 14-year-old boy had undergone an orbitozygomatic craniotomy for a pontine lesion. There was growth on surveillance imaging with involvement of posterior clinoids, clivus, and left pons suggestive of chordoma (Fernandez-Miranda et al., 2014b). An endoscopic endonasal approach was undertaken involving full upper and midclival exposure including bilateral posterior clinoidectomy (Fernandez-Miranda et al., 2014a; Truong et al., 2019a, 2019b). The internal carotid artery was skeletonized to maximize exposure and facilitate safe resection. The tumor was removed from between the dural layers of the midclivus while preserving the interdural abducens nerve (Barges-Coll et al., 2010). The brainstem component was resected while preserving the pontine perforators. Postoperative diagnosis was chordoma with MRI demonstrating complete resection. The patient was intact postoperatively. The video can be found here: https://youtu.be/g6SQ5JVK0Ko.

    View details for DOI 10.3171/2019.10.FocusVid.19421

    View details for PubMedID 36284860

    View details for PubMedCentralID PMC9541825

  • Validation of a rhinologic virtual surgical simulator for performing a Draf 3 endoscopic frontal sinusotomy Won, T., Cho, S., Sung, M., Paek, S., Chan, S., Salisbury, K., Blevins, N. H., Vaisbuch, Y., Hwang, P. WILEY. 2019: 910–17

    View details for DOI 10.1002/alr.22333

    View details for Web of Science ID 000479060500012

  • Nasopharyngeal Angiofibroma Staging with a Novel Nominal Basis: An 18-Year Study in a Tertiary Center OTOLARYNGOLOGY-HEAD AND NECK SURGERY Abdelwahab, M., Overdevest, J. B., Elmokadem, A., El-Sisi, H., El-Kholy, N., Zaki, H., Kamal, E., Khafagy, Y., Tawfik, A., Eldawoody, H., Hwang, P., Rakha, A. 2019; 161 (2): 352–61
  • ICAR: endoscopic skull-base surgery. International forum of allergy & rhinology Wang, E. W., Zanation, A. M., Gardner, P. A., Schwartz, T. H., Eloy, J. A., Adappa, N. D., Bettag, M., Bleier, B. S., Cappabianca, P., Carrau, R. L., Casiano, R. R., Cavallo, L. M., Ebert, C. S., El-Sayed, I. H., Evans, J. J., Fernandez-Miranda, J. C., Folbe, A. J., Froelich, S., Gentili, F., Harvey, R. J., Hwang, P. H., Jane, J. A., Kelly, D. F., Kennedy, D., Knosp, E., Lal, D., Lee, J. Y., Liu, J. K., Lund, V. J., Palmer, J. N., Prevedello, D. M., Schlosser, R. J., Sindwani, R., Solares, C. A., Tabaee, A., Teo, C., Thirumala, P. D., Thorp, B. D., de Arnaldo Silva Vellutini, E., Witterick, I., Woodworth, B. A., Wormald, P., Snyderman, C. H. 2019; 9 (S3): S145–S365

    Abstract

    BACKGROUND: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).METHODS: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.RESULTS: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.CONCLUSION: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

    View details for DOI 10.1002/alr.22326

    View details for PubMedID 31329374

  • Workforce analysis of practicing rhinologists in the united states. The Laryngoscope Heineman, T. E., Ramakrishnan, V., Hwang, P. H., Suh, J. D. 2019

    Abstract

    OBJECTIVES: The objective of this study is to analyze the current rhinology workforce in the United States in terms of demographics, fellowship training, and regional distribution.METHODS: The American Rhinologic Society (ARS) member database was queried for workplace zip code, age, gender, and fellowship training of practicing U.S. rhinologists through 2017. The San Francisco Match data were examined for rhinology fellowships from 2006 through 2017. Each rhinologist was assigned to a specific hospital referral region (HRR) determined by the Dartmouth Healthcare Atlas to assess geographic distribution and market density.RESULTS: There were 296 ARS members self-identifying as rhinologists. Of those, 69.2% were fellowship-trained (FTR). The median age of FTRs and non-FTRs were 41 and 54 years, respectively (P <0.001). Eighty percent of FTRs were male compared to 85.7% non-FTRs. Given the recent growth of rhinology fellowships, the number of FTRs is currently expanding at approximately 16% per year. HRRs with the most rhinologists were Los Angeles, Boston, and Manhattan, all with 14. Approximately 100 million people live in HRRs without a practicing rhinologist. A wide variation in rhinologist density was observed, ranging from 133,047 to 3,636,809 people per rhinologist, with a median of 747,864.CONCLUSION: There may be a need for rhinologists in select parts of the country. Whereas the ARS database is likely an underestimation of the growing workforce, under current training rates we could pass the ideal number of U.S. rhinologists within 5 years.LEVEL OF EVIDENCE: NA Laryngoscope, 2019.

    View details for DOI 10.1002/lary.28157

    View details for PubMedID 31246279

  • Outcomes of sinonasal inverted papilloma resection by surgical approach: an updated systematic review and meta-analysis Peng, R., Thamboo, A., Choby, G., Ma, Y., Zhou, B., Hwang, P. H. WILEY. 2019: 573–81

    View details for DOI 10.1002/alr.22305

    View details for Web of Science ID 000470911800002

  • Topical Corticosteroid Pretreatment Mitigates Cellular Damage After Caustic Injury to the Nasal Upper Airway Epithelium AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Huang, Z., Velasquez, N., Nguyen, A., Ye, T., Le, W., Bravo, D. T., Hwang, P. H., Zhou, B., Nayak, J. 2019; 33 (3): 277–85
  • Nasopharyngeal Angiofibroma Staging with a Novel Nominal Basis: An 18-Year Study in a Tertiary Center. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Abdelwahab, M., Overdevest, J. B., Elmokadem, A., El-Sisi, H., El-Kholy, N. A., Zaki, H., Kamal, E., Khafagy, Y., Tawfik, A., Eldawoody, H., Hwang, P., Rakha, A. 2019: 194599819842155

    Abstract

    OBJECTIVE: To develop a systematic method for anatomic mapping of juvenile nasopharyngeal angiofibroma (JNA) tumors to standardize communication, facilitate surgical planning, and convey prognosis.STUDY DESIGN: Retrospective cohort.SETTING: Tertiary referral center.SUBJECTS AND METHODS: Following Institutional Review Board approval, we performed a retrospective review of radiologic and angiographic data of patients with JNA presenting to the Department of Otolaryngology-Head and Neck Surgery, Mansoura University, from 2001 to 2017. All patients underwent angiography with embolization and had >1-year follow-up. Based on frequently involved anatomic sites and factors predictive of prognosis, the NSF-COR staging system (nose/nasopharynx, sinus, fossa-cranium, orbit, residual internal carotid artery supply) was developed to explicitly convey anatomic site of involvement and presence of residual vascularity. We validated the NSF-COR staging system against other systems with Pearson chi-square test based on risk factors and clinical outcomes of blood transfusion volume, recurrence, and JNA resectability.RESULTS: Fifty-four patients met inclusion criteria, where all primary cases (100%) demonstrated nose/nasopharynx involvement, followed by sinus (85.2%), natural fossae (85.2%), intracranial (26%), and orbital involvement (16.7%). These sites, with assessment of residual internal carotid artery vascular supply, were used to develop the NSF-COR anatomically based staging system. The components COR showed significant association with clinical outcomes of blood transfusion and recurrence. Contingency coefficients between the NSF-COR staging system and available staging systems showed significant correlations ( P < .05) for prognosis.CONCLUSION: The NSF-COR staging system conveys a communicable anatomic map of JNA tumors that integrates residual vascularity of the tumor and demonstrates strong concordance with current staging systems to assess clinical outcomes.

    View details for PubMedID 31012381

  • Microcurrent technology for rapid relief of sinus pain: a randomized, placebo-controlled, double-blinded clinical trial Maul, X. A., Borchard, N. A., Hwang, P. H., Nayak, J. V. WILEY. 2019: 352–56

    View details for DOI 10.1002/alr.22280

    View details for Web of Science ID 000468167600004

  • Imaging predictors for malignant transformation of inverted papilloma Yan, C. H., Tong, C. L., Penta, M., Patel, V. S., Palmer, J. N., Adappa, N. D., Nayak, J. V., Hwang, P. H., Patel, Z. M. WILEY. 2019: 777–82

    View details for DOI 10.1002/lary.27582

    View details for Web of Science ID 000462650400015

  • Outcomes of sinonasal inverted papilloma resection by surgical approach: an updated systematic review and meta-analysis. International forum of allergy & rhinology Peng, R., Thamboo, A., Choby, G., Ma, Y., Zhou, B., Hwang, P. H. 2019

    Abstract

    BACKGROUND: Selecting the optimal surgical approach for resection of sinonasal inverted papilloma (SIP) remains a challenge, with endoscopic, external, and combined approaches being utilized. This systematic review was conducted as an update to a 2006 systematic review to determine the preferred surgical approach for tumor control.METHODS: The study protocol was developed a priori following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. Data were collected and outcomes were analyzed according to surgical approach and sites of tumor involvement.RESULTS: A total of 96 papers and 4134 SIP patients were included. The overall recurrence rate was 12.80% (322/2515) for the endoscopic approach group, 16.58% (182/1098) for the external approach group, and 12.60% (65/516) for the combined approach group. Meta-analysis by random effects model showed that the summarized risk ratio (RR) of recurrence was 0.61 (95% confidence interval [CI], 0.44 to 0.85, p = 0.003), I2 = 37.95% for the endoscopic vs external approach; 0.98 (95% CI, 0.69 to 1.39, p = 0.901), I2 = 9.06% for the endoscopic vs combined approach; 1.61 (95% CI, 1.06 to 2.43, p = 0.025), I2 = 0.00% for the external vs combined approach. After adjusting for publication bias, the adjusted RRs were 0.66 (p = 0.014) for endoscopic vs external; 0.99 (p = 0.955) for endoscopic vs combined; and 1.33 (p = 0.224) for external vs combined.CONCLUSION: An enlarging and maturing body of literature continues to indicate that endoscopic approaches result in significantly lower recurrence rates than open approaches for surgical resection of SIP.

    View details for PubMedID 30748098

  • Topical Corticosteroid Pretreatment Mitigates Cellular Damage After Caustic Injury to the Nasal Upper Airway Epithelium. American journal of rhinology & allergy Huang, Z., Velasquez, N., Nguyen, A., Ye, T., Le, W., Bravo, D. T., Hwang, P. H., Zhou, B., Nayak, J. V. 2019: 1945892418823305

    Abstract

    BACKGROUND: Topical corticosteroids are currently employed to reduce established airway inflammation; their prophylactic use might help limit cellular damage against harmful stimuli.OBJECTIVES: To determine the effects of a prophylactic topical application of budesonide (BD) on an in vivo nasal epithelium injury model induced by trichloroacetic acid (TCA).METHODS: C57Bl/6 mice were exposed to intranasal TCA topical application. Three groups received topical intranasal BD, saline solution, or no intervention prior to a single topical exposure to TCA. Controls were not exposed to TCA. Whole nasal cavity coronal sections were analyzed at 1, 3, and 6 days postinjury at tissue and cellular levels using histopathological analysis, immunofluorescent staining, and fresh tissue RNA microarray analysis.RESULTS: Prophylactic topical corticosteroid exposure protected the nasal epithelium from acute damage, maintaining epithelial thickness and cell survival. Six days following TCA exposure, epithelial and cellular changes were less pronounced on the BD-treated group compared to all exposure groups. The microarray analysis was used to evaluate the gene transcripts in all treatment groups. Ciliary tip protein, Sentan, and submucosal protein S100b were identified as potential factors in epithelial airway protection; immunofluorescent staining corroborated their presence and location within the respiratory epithelium.CONCLUSION: Topical corticosteroid treatment to the nasal epithelium can mitigate several of the early deleterious effects of acute epithelial damage in experimental airway injuries caused by TCA. These findings suggest a novel, direct cytoprotective effect of corticosteroids on the nasal epithelium, and the potential of expanding the use of prophylactic periprocedural topical corticosteroids for respiratory epithelial tissues.

    View details for PubMedID 30638033

  • Neutrophil Extracellular Traps Induce Tissue-Invasive Monocytes in Granulomatosis With Polyangiitis. Frontiers in immunology Akiyama, M. n., Zeisbrich, M. n., Ibrahim, N. n., Ohtsuki, S. n., Berry, G. J., Hwang, P. H., Goronzy, J. J., Weyand, C. M. 2019; 10: 2617

    Abstract

    Objective: Granulomatosis with polyangiitis (GPA) is a multi-organ vasculitic syndrome typically associated with neutrophil extracellular trap (NET) formation and aggressive tissue inflammation. Manifestations in head and neck (H&N) GPA include septal perforations, saddle-nose deformities, bony erosions of the orbital and sinus walls, middle ear damage and epiglottitis, indicative of bone, cartilage, and connective tissue destruction. Whether H&N-centric lesions engage disease pathways distinctive from the ischemic tissue damage in the lungs, kidneys, skin, and peripheral nerves is unknown. We have compared inflammatory responses triggered by neutrophilic NETs in patients with H&N GPA and systemic GPA (sGPA). Methods: Neutrophils and monocytes were isolated from the peripheral blood of patients with H&N GPA, sGPA, and age/gender matched healthy individuals. Neutrophil NETosis was induced. NETs were isolated and cocultured with monocytes. Gene induction was quantified by RT-PCR, protein upregulation by flow cytometry. Tissue invasiveness of monocytes was measured in a 3D collagen matrix system. Expression of MMP-9 in tissue-residing macrophages was assessed by immunohistochemistry in tissue biopsies. Results: Neutrophils from H&N GPA patients showed more intense NETosis with higher frequencies of netting neutrophils (P < 0.001) and release of higher amounts of NETs (P < 0.001). Isolated NETs from H&N GPA functioned as an inducer of danger-associated molecular patterns in monocytes; specifically, alarmin S100A9. NET-induced upregulation of monocyte S100A9 required recognition of DNA. S100A9 release resulted in the induction of metalloproteinases, including MMP-9, and enabled monocytes to invade into extracellular matrix. Anti-MMP-9 treatment attenuated the tissue invasiveness of monocytes primed with NETs from H&N GPA patients. MMP-9-producing macrophages dominated the tissue infiltrates in naso-sinal biopsies from H&N GPA patients. Conclusion: Distinct disease patterns in GPA are associated with differences in NET formation and NET content. H&N GPA patients with midline cartilaginous and bony lesions are highly efficient in generating NETs. H&N GPA neutrophils trigger the induction of the alarmin S100A9, followed by production of MMP-9, endowing monocytes with tissue-invasive capabilities.

    View details for DOI 10.3389/fimmu.2019.02617

    View details for PubMedID 31798577

    View details for PubMedCentralID PMC6874157

  • Cryosurgical ablation for treatment of rhinitis: A prospective multicenter study. The Laryngoscope Chang, M. T., Song, S. n., Hwang, P. H. 2019

    Abstract

    To assess the efficacy and safety of cryoablation of the posterior nasal nerve (PNN) for treatment of chronic rhinitis.This was a prospective single-arm trial of 98 adult patients at six U.S. centers with chronic allergic and nonallergic rhinitis. PNN cryoablation was performed in-office under local anesthesia using a handheld device. Patients discontinued use of intranasal ipratropium 3 days prior to treatment and throughout the study period. Reflective Total Nasal Symptom Score (rTNSS) was measured at pretreatment baseline and posttreatment at 1 month, 3 months, 6 months, and 9 months. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was completed at pretreatment and 3 months posttreatment. Adverse effects and postprocedure medication usage were recorded.Ninety-eight procedures (100%) were successfully completed. rTNSS significantly improved over pretreatment baseline (6.1 ± 1.9) at 1 month (2.9 ± 1.9, P < 0.001), 3 months (3.0 ± 2.3, P < 0.001), 6 months (3.0 ± 2.1, P < 0.001), and 9 months (3.0 ± 2.4, P < 0.001) postprocedure. Nasal congestion and rhinorrhea subscores improved significantly at all time points (P < 0.001). Both allergic and nonallergic rhinitis subcohorts showed improvement (P < 0.001), with a comparable degree of improvement between groups. RQLQ significantly improved over pretreatment baseline (3.0 ± 1.0) at 3 months (1.5 ± 1.0, P < 0.001), and all RQLQ subdomains demonstrated improvement. Of 54 patients using intranasal medication at baseline, 19 (35.2%) were able to discontinue use. Twenty-nine adverse effects were reported, including headache, epistaxis, and sinusitis.Cryoablation of the PNN for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life.4 Laryngoscope, 2019.

    View details for DOI 10.1002/lary.28301

    View details for PubMedID 31566744

  • A call for mentorship in otolaryngology BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY Hwang, P. H. 2019; 85 (1): 1–2
  • The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: a double-blind randomized controlled study. International forum of allergy & rhinology Tangbumrungtham, N. n., Hwang, P. H., Maul, X. n., Borchard, N. A., Dholakia, S. S., Patel, Z. M., Nayak, J. V., Choby, G. n. 2019

    Abstract

    The objective of this study is to determine whether the infiltration of 1% lidocaine with 1:100,000 epinephrine in addition to topical application of 1:1000 epinephrine significantly improves surgical field grading scale score over topical 1:1000 epinephrine alone.A prospective, double-blind, randomized, controlled study was performed of 40 patients undergoing bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Patients were enrolled and randomly assigned to receive infiltration with 1% lidocaine with 1:100,000 epinephrine on 1 side of the nasal cavity vs plain saline on the other side in preparation for ESS. Both groups received topical application of 1:1000 epinephrine. Surgical videos were recorded and Wormald surgical field grading scale was assigned by 2 blinded reviewers. The number of extra 1:1000 epinephrine pledgets used during the surgery, estimated blood loss, and surgical duration were also recorded.There were no statistically significant differences in Wormald surgical field grading scale, number of extra pledgets used, or estimated blood loss between the nasal cavity side infiltrated with 1% lidocaine with 1:100,000 epinephrine in comparison to infiltration with saline. The side infiltrated with 1% lidocaine with 1:100,000 epinephrine had a reduced operative time compared to the side infiltrated with saline (p = 0.002). There were no differences in postoperative bleeding from questionnaire completed by patient at the first postoperative visit.Addition of infiltration of 1% lidocaine with epinephrine 1:100,000 to topical application of epinephrine 1:1000 for preparation of ESS does not significantly improve surgical field of view compared to topical epinephrine alone.

    View details for DOI 10.1002/alr.22468

    View details for PubMedID 31671251

  • Postoperative Care Following Transnasal Endoscopic Skull Base and Brain Surgery TRANSNASAL ENDOSCOPIC SKULL BASE AND BRAIN SURGERY: SURGICAL ANATOMY AND ITS APPLICATIONS, 2ND EDITION Choby, G. W., Hwang, P. H., Stamm, A. C. 2019: 104–9
  • High-Efficiency, Selection-free Gene Repair in Airway Stem Cells from Cystic Fibrosis Patients Rescues CFTR Function in Differentiated Epithelia. Cell stem cell Vaidyanathan, S. n., Salahudeen, A. A., Sellers, Z. M., Bravo, D. T., Choi, S. S., Batish, A. n., Le, W. n., Baik, R. n., de la O, S. n., Kaushik, M. P., Galper, N. n., Lee, C. M., Teran, C. A., Yoo, J. H., Bao, G. n., Chang, E. H., Patel, Z. M., Hwang, P. H., Wine, J. J., Milla, C. E., Desai, T. J., Nayak, J. V., Kuo, C. J., Porteus, M. H. 2019

    Abstract

    Cystic fibrosis (CF) is a monogenic disorder caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. Mortality in CF patients is mostly due to respiratory sequelae. Challenges with gene delivery have limited attempts to treat CF using in vivo gene therapy, and low correction levels have hindered ex vivo gene therapy efforts. We have used Cas9 and adeno-associated virus 6 to correct the ΔF508 mutation in readily accessible upper-airway basal stem cells (UABCs) obtained from CF patients. On average, we achieved 30%-50% allelic correction in UABCs and bronchial epithelial cells (HBECs) from 10 CF patients and observed 20%-50% CFTR function relative to non-CF controls in differentiated epithelia. Furthermore, we successfully embedded the corrected UABCs on an FDA-approved porcine small intestinal submucosal membrane (pSIS), and they retained differentiation capacity. This study supports further development of genetically corrected autologous airway stem cell transplant as a treatment for CF.

    View details for DOI 10.1016/j.stem.2019.11.002

    View details for PubMedID 31839569

  • Validation of a rhinologic virtual surgical simulator for performing a Draf 3 endoscopic frontal sinusotomy. International forum of allergy & rhinology Won, T. B., Cho, S. W., Sung, M. W., Paek, S. H., Chan, S. n., Salisbury, K. n., Blevins, N. H., Vaisbuch, Y. n., Hwang, P. n. 2019

    Abstract

    We recently introduced a patient-specific rhinologic virtual surgical environment (VSE) that has shown potential for surgical rehearsal of various skull base lesions. Our aim in this study was to validate the usefulness of the rhinology VSE in performing the Draf 3 procedure.An outside-in Draf 3 procedure was performed on 4 cadaver heads. Computed tomography (CT) scans were obtained before and after cadaver dissection (CD). Pre-dissection CT scans were used to construct a cadaver-specific VSE. A virtual Draf 3 dissection (VD) was performed using the same technique. Validation was conducted by comparing the final common frontal outflow tract. A subjective comparison of the post-dissection endoscopic findings (CD vs VD) and an objective measurement using the post-dissection CT scan for the CD and the reconstructed CT scan obtained from the data after the VD was performed.Subjective overall resemblance of the 2 dissections (CD vs VD) assessed by the 4-point Likert scale (0-3) was 2.5 (median interquartile range [IQR], 0.25) for the 4 cadavers. The median difference for the anteroposterior dimension of the frontal neo-ostium (CD vs VD) assessed in the midsagittal view was 0.11 mm, whereas the median difference for the lateral dimension assessed in the coronal view was 2.71 mm. Thus, no statistical difference was observed.VD showed nearly matching results with the actual cadaver dissection. With further validation, our rhinologic VSE may be used for presurgical planning and rehearsal before the actual Draf 3 procedure is performed in the operating room.

    View details for PubMedID 31012526

  • Role of inferior turbinate reduction in the quality of life of patients undergoing endoscopic sinus surgery for chronic rhinosinusitis. International forum of allergy & rhinology Soudry, E. n., Mace, J. n., Smith, T. L., Hwang, P. H. 2019

    Abstract

    The impact on quality of life (QoL) of bilateral inferior turbinate reduction (BITR) performed in the setting of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) has been a point of controversy. The aim of this study was to determine whether addition of BITR to ESS is associated with improved QoL when compared with ESS alone.This study presented findings a multi-institutional, retrospective analysis of a prospective open cohort of patients electing ESS for failed medical management of CRS. QoL parameters were compared between patients who underwent ESS alone vs those who underwent ESS with BITR.A total of 571 patients with CRS who elected to undergo ESS were identified. Sixty-one of these patients also underwent concurrent BITR, whereas 510 patients underwent ESS without BITR. Mean length of follow-up was 15.1 months. Comparison between baseline and last postoperative QoL, olfaction, and endoscopic scores revealed significant improvement in both groups. Overall, BITR surgery was not significantly associated with clinically significant incremental improvement in QoL in either the polyp or non-polyp group. Nevertheless, statistically significant improvement was noted for the nasal congestion/blockage symptom in polyp patients (p = 0.006) and in primary surgery patients (p = 0.027) who underwent BITR.BITR in the setting of ESS for CRS is not associated with significant incremental improvement in overall QoL vs ESS alone. However, BITR in polyp and primary surgery patients undergoing ESS appears to offer a significant incremental improvement in nasal congestion/blockage symptoms compared with ESS alone. Future studies are warranted to better corroborate these findings.

    View details for DOI 10.1002/alr.22356

    View details for PubMedID 31220413

  • Transnasal endoscopic approach for pediatric skull base lesions: a case series. Journal of neurosurgery. Pediatrics Quon, J. L., Kim, L. H., Hwang, P. H., Patel, Z. M., Grant, G. A., Cheshier, S. H., Edwards, M. S. 2019: 1–12

    Abstract

    Transnasal endoscopic transsphenoidal approaches constitute an essential technique for the resection of skull base tumors in adults. However, in the pediatric population, sellar and suprasellar lesions have historically been treated by craniotomy. Transnasal endoscopic approaches are less invasive and thus may be preferable to craniotomy, especially in children. In this case series, the authors present their institutional experience with transnasal endoscopic transsphenoidal approaches for pediatric skull base tumors.The authors retrospectively reviewed pediatric patients (age ≤ 18 years) who had undergone transnasal endoscopic transsphenoidal approaches for either biopsy or resection of sellar or suprasellar lesions between 2007 and 2016. All operations were performed jointly by a team of pediatric neurosurgeons and skull base otolaryngologists, except for 8 cases performed by one neurosurgeon.The series included 42 patients between 4 and 18 years old (average 12.5 years) who underwent 51 operations. Headache (45%), visual symptoms (69%), and symptoms related to hormonal abnormalities (71%) were the predominant presenting symptoms. Improvement in preoperative symptoms was seen in 92% of cases. Most patients had craniopharyngiomas (n = 16), followed by pituitary adenomas (n = 12), Rathke cleft cysts (n = 4), germinomas (n = 4), chordomas (n = 2), and other lesion subtypes (n = 4). Lesions ranged from 0.3 to 6.2 cm (median 2.5 cm) in their greatest dimension. Gross-total resection was primarily performed (63% of cases), with 5 subsequent recurrences. Nasoseptal flaps were used in 47% of cases, fat grafts in 37%, and lumbar drains in 47%. CSF space was entered intraoperatively in 15 cases, and postoperative CSF was observed only in lesions with suprasellar extension. There were 8 cases of new hormonal deficits and 3 cases of new cranial nerve deficits. Length of hospital stay ranged from 1 to 61 days (median 5 days). Patients were clinically followed up for a median of 46 months (range 1-120 months), accompanied by a median radiological follow-up period of 45 months (range 3.8-120 months). Most patients (76%) were offered adjuvant therapy.In this single-institution report of the transnasal endoscopic transsphenoidal approach, the authors demonstrated that this technique is generally safe and effective for different types of pediatric skull base lesions. Favorable effects of surgery were sustained during a follow-up period of 4 years. Further refinement in technology will allow for more widespread use in the pediatric population.

    View details for DOI 10.3171/2019.4.PEDS18693

    View details for PubMedID 31200365

  • Imaging predictors for malignant transformation of inverted papilloma. The Laryngoscope Yan, C. H., Tong, C. C., Penta, M., Patel, V. S., Palmer, J. N., Adappa, N. D., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2018

    Abstract

    OBJECTIVES/HYPOTHESIS: Inverted papillomas (IPs) are benign tumors of the sinonasal tract with a malignant transformation potential. Predicting the transformation propensity of IPs and corresponding risk factors has long been a challenge. In this study, we aimed to use radiographic findings on magnetic resonance imaging (MRI) and computed tomography (CT) to help differentiate IP from IP-transformed squamous cell carcinomas (IP-SCC).STUDY DESIGN: Retrospective cohort study.METHODS: A retrospective analysis was performed at two institutions comparing IP (n=76) and IP-SCC (n=66) tumors, evaluating preoperative radiographic imaging with corresponding surgical pathology reports. The presence of a convoluted cerebriform pattern (CCP) using postcontrast T1-weighted and T2-weighted MRI was evaluated. Using MRI diffusion-weighted imaging (DWI), we calculated the apparent diffusion coefficient (ADC) value of each tumor. We also determined the tumor origin, attachment sites, and presence of bony erosion using CT imaging.RESULTS: Benign IPs had a higher prevalence of CCP on MRI compared to IP-transformed SCC (P=.0001. The mean value ADC of malignant IP-SCC (ADCb0,1000 =1.12*10-3 mm2 /s) was significantly lower than that of benign IPs (ADCb0,1000 =1.49*10-3 mm2 /s, P=.002). IP-SCC tumors were more likely to be have orbital wall attachment (P=.002) and bony erosion (P<.0001) compared to IPs.CONCLUSIONS: Evaluation of CCP and DWI with ADC values on MRI are promising qualitative and quantitative methods to help differentiate benign IP tumors from their transformed malignant counterparts. Malignant IP-SCCs are associated with a loss of CCP and lower ADC values. Findings of orbital wall involvement and bony erosion on CT may also help determine presence of malignancy.LEVEL OF EVIDENCE: 4 Laryngoscope, 2018.

    View details for PubMedID 30515841

  • A multi-institutional review of outcomes in biopsy-proven acute invasive fungal sinusitis Wandell, G. M., Miller, C., Rathor, A., Wai, T., Guyer, R. A., Schmidt, R. A., Turner, J. H., Hwang, P. H., Davis, G. E., Humphreys, I. M. WILEY. 2018: 1459–68

    Abstract

    Acute invasive fungal sinusitis (AIFS) is a rare, aggressive infection occurring in immunocompromised patients. In this study we examined factors that affect survival in AIFS, and whether immune-stimulating therapies (IST) improve survival.Pathology records of biopsy-proven AIFS were reviewed from 3 academic institutions from 1995 to 2016. Univariate and multivariate Cox regressions were performed at 1 and 3 months from diagnosis.One hundred fourteen patients were included; 45 received IST. In the univariate analysis, the following factors were associated with worse survival: hematologic malignancy (3-month hazard ratio [HR], 3.7; p = 0.01); recent chemotherapy (within 1 month of AIFS diagnosis) (3-month HR, 2.3; p = 0.02); recent bone marrow transplant (BMT) (3-month HR, 2.5; p = 0.02); and infection with atypical fungi (1-month HR, 3.1; p = 0.04). The following were associated with improved survival in univariate analysis: increasing A1c% (1-month HR, 0.7; p = 0.01) and surgical debridement (1-month HR, 0.1; p = 0.001). One third of patients with a hematologic malignancy had an absolute neutrophil count (ANC) >1000 at the time of diagnosis. ANC was not associated with prognosis in these patients. The following were associated with worse survival in multivariate analyses: hematologic malignancy; recent chemotherapy; atypical organisms; and cavernous sinus extension. In multivariate analyses, IST was associated with a 70% reduction in mortality at 1 month (p = 0.02).We presented the largest series of AIFS. Further studies are needed to examine the importance of ANC in diagnosis and prognosis. Patients diagnosed with atypical organisms may be at higher risk of death. IST likely improves short-term survival, but prospective studies are needed.

    View details for PubMedID 29979836

  • Precision medicine: why surgeons deviate from "appropriateness criteria" in the management of chronic rhinosinusitis and effects on outcomes Thamboo, A., Rathor, A., Borchard, N. A., Nayak, J. V., Hwang, P. H., Patel, Z. M. WILEY. 2018: 1389–94

    View details for DOI 10.1002/alr.22184

    View details for Web of Science ID 000453516400004

  • A call for mentorship in otolaryngology. Brazilian journal of otorhinolaryngology Hwang, P. H. 2018

    View details for PubMedID 30472005

  • Moving slowly but surely toward more precise rhinologic care INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Hwang, P. H. 2018; 8 (10): 1081–82

    View details for DOI 10.1002/alr.22215

    View details for Web of Science ID 000446274900001

    View details for PubMedID 30216706

  • Surgical Management of Nonallergic Rhinitis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Yan, C. H., Hwang, P. H. 2018; 51 (5): 945-+
  • Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Nayak, J. V., Rathor, A., Grayson, J. W., Bravo, D. T., Velasquez, N., Noel, J., Beswick, D. M., Riley, K. O., Patel, Z. M., Cho, D., Dodd, R. L., Thamboo, A., Choby, G. W., Walgama, E., Harsh, G. R., Hwang, P. H., Clemons, L., Lowman, D., Richman, J. S., Woodworth, B. A. 2018; 8 (10): 1162–68

    View details for DOI 10.1002/alr.22156

    View details for Web of Science ID 000446274900013

  • Effect of Endoscopic Sinus Surgery on Bronchiectasis Patients With Chronic Rhinosinusitis AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Kanjanaumporn, J., Hwang, P. H. 2018; 32 (5): 432–39

    Abstract

    Background The concept of unified airway disease has linked bronchiectasis with chronic rhinosinusitis (CRS), much in the same way as in asthma and CRS. Although the outcomes of endoscopic sinus surgery (ESS) on comorbid asthma have been relatively well studied, the outcomes of ESS on comorbid bronchiectasis have rarely been examined. Objective We sought to determine sinonasal and pulmonary clinical outcomes of ESS in bronchiectasis patients with CRS. Method We reviewed all bronchiectasis patients who had ESS for CRS at our institution from 2006 to present. The sinonasal outcome test 22 (SNOT-22) was administered preoperatively and at 3 months, 1 year, and 3 years postoperatively. Pulmonary function tests (PFTs) were measured preoperatively and at 6 months and 1 year post operation to assess the forced expiratory volume in 1 s (FEV1), forced viral capacity (FVC), and FEV1/FVC values. Paired t test and Pearson correlation were used to compare pre- and postsurgical results. Results A total of 141 bronchiectasis patients who had ESS for CRS were studied. The most common cause of bronchiectasis was cystic fibrosis (CF) (42.55%). SNOT-22 scores improved at 3 months post operation and were maintained at 1 year and 3 years post operation ( P < .001). All SNOT sub-domains showed a significant improvement after surgery ( P < .01). However, PFTs did not change at 6 months post operation and 1 year post operation ( P > .05). There were significant differences in the outcomes in CF versus non-CF patients ( P < .05) but not by sex or age. Conclusion ESS is effective in improving long-term sinonasal outcomes in bronchiectasis patients with CRS. However, ESS does not appear to improve the pulmonary function.

    View details for PubMedID 30112923

  • Comparison of outcomes following culture-directed vs non-culture-directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis Yan, C. H., Tangbumrungtham, N., Maul, X. A., Ma, Y., Nayak, J. V., Hwang, P. H., Patel, Z. M. WILEY. 2018: 1028–33

    View details for DOI 10.1002/alr.22147

    View details for Web of Science ID 000443132000008

  • Orbital Apex Lesions: A Diagnostic and Therapeutic Challenge JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Cho, S., Lee, W., Ma, D., Kim, J., Han, D., Kim, H., Kim, D., Kim, S., Khwarg, S., Kim, S., Paek, S., Rhee, C., Lee, C., Hwang, P. H., Won, T. 2018; 79 (4): 386–93

    Abstract

    Objective  To analyze the clinical characteristics of and treatment outcomes for orbital apex lesions according to their pathological diagnosis and identify clinical characteristics that could aid in their differential diagnosis. Design  Retrospective analysis design was used for this study. Setting  The study was conducted in a single tertiary institution. Participants  Patients with pathologically confirmed lesions centered in the orbital apex who were admitted between January 2011 and December 2015. Main Outcome Measures  Clinical characteristics, including demographics, predisposing factors, presenting symptoms, radiological findings, intraoperative findings, biopsy results, and treatment outcomes. Results  Nine patients with invasive fungal sinusitis, six with inflammatory pseudotumor, and six with neoplastic or tumorous lesions were enrolled. The most common presenting symptom was orbital pain or headache, followed by ophthalmoplegia and vision loss, which exhibited overall recovery rates of 62.5% and 33.3%, respectively, after definitive treatment. The prognosis was worse for patients with invasive fungal sinusitis. There was no significant difference in age, underlying medical conditions, absolute neutrophil count, C-reactive protein level, and radiological findings among the three groups. Grossly necrotic tissues around the orbital apex area at biopsy were more frequently found in patients with invasive fungal sinusitis than in the other patients. In most cases, pain ameliorated after surgical intervention. There were no surgery-related morbidities. Conclusions  Lesions centered in the orbital apex included invasive fungal sinusitis, inflammatory pseudotumor, and tumorous lesions. However, clinical features that clearly differentiated chronic invasive fungal sinusitis from inflammatory pseudotumor could not be identified. Our findings suggest that prompt biopsy is warranted for timely diagnosis, symptom relief, and early implementation of definitive treatment.

    View details for PubMedID 30009120

    View details for PubMedCentralID PMC6043169

  • 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

    Abstract

    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

  • Precision medicine: why surgeons deviate from "appropriateness criteria" in the management of chronic rhinosinusitis and effects on outcomes. International forum of allergy & rhinology Thamboo, A., Rathor, A., Borchard, N. A., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2018

    Abstract

    BACKGROUND: In uncomplicated chronic rhinosinusitis (CRS), a consensus regarding appropriate medical therapy (AMT) before surgical intervention has been published in the form of "appropriateness criteria" for endoscopic sinus surgery (ESS). We sought to determine why tertiary surgeons may deviate from the suggested criteria and evaluated whether those deviations result in change in outcomes.METHODS: Patients with uncomplicated CRS were prospectively enrolled over the course of 1 year. The 22-item Sino-Nasal Outcomes Test (SNOT-22), a general health outcome out of 100, and a physician form, indicating management pathway and decision making, was completed at each visit over a 6-month follow-up period. A descriptive analysis was used to quantify reasons for veering from the "appropriateness criteria," and repeated linear regression modeling was used to measure whether compliance impacted SNOT-22, general health, and Lund-Kennedy (LK) scores over the period of study.RESULTS: One hundred fifty-five patients were enrolled. Sixty-eight percent followed the appropriate management pathway based on their presentation and the suggested criteria. Disparate reasons were documented for deviation in the other 32%, and, despite establishing several predictive categories, "other" was the most common reason, with various explanations well documented. SNOT-22, general health, and LK scores were not statistically impacted by compliancy status (p > 0.05).CONCLUSION: The suggested "appropriateness criteria" predict a management pathway for the majority of CRS patients. However, in a tertiary sinus center, surgeons may deviate from that model with a significant minority of their patients, for multiple reasons, without causing a change in outcomes.

    View details for PubMedID 29999595

  • Computed tomography analysis of frontal cell prevalence according to the International Frontal Sinus Anatomy Classification INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Choby, G., Thamboo, A., Won, T., Kim, J., Shih, L., Hwang, P. H. 2018; 8 (7): 825–30

    View details for DOI 10.1002/alr.22105

    View details for Web of Science ID 000437764300009

  • Building the Evidence for Corticosteroid Irrigation Therapy in Chronic Rhinosinusitis JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY Hwang, P. H. 2018; 144 (7): 612–13
  • Nasoseptal Flap Closure of the Eustachian Tube for Recalcitrant Cerebrospinal Fluid Rhinorrhea LARYNGOSCOPE Patel, V. S., Choby, G. W., Thamboo, A., Blevins, N. H., Hwang, P. H. 2018; 128 (7): 1523–26

    View details for DOI 10.1002/lary.26988

    View details for Web of Science ID 000440007000017

  • Surgical Management of Nonallergic Rhinitis. Otolaryngologic clinics of North America Yan, C. H., Hwang, P. H. 2018

    Abstract

    Nonallergic rhinitis (NAR) describes chronic symptoms of nasal congestion, obstruction, and rhinorrhea unrelated to a specific allergen based on skin or serum testing. Vasomotor rhinitis is the most frequent subtype of NAR. Although medical management is the first-line treatment of NAR, there is a role for surgical therapy when medications fail to improve symptoms. Surgical options for NAR include inferior turbinate reduction and botulinum toxin injection as well as more directed targeting of the autonomic nerve supply to the nasal cavity through vidian neurectomy, posterior nasal neurectomy, and cryoablation of the posterior nerve.

    View details for PubMedID 29937065

  • Building the Evidence for Corticosteroid Irrigation Therapy in Chronic Rhinosinusitis. JAMA otolaryngology-- head & neck surgery Hwang, P. H. 2018

    View details for PubMedID 29879273

  • Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling. International forum of allergy & rhinology Nayak, J. V., Rathor, A., Grayson, J. W., Bravo, D. T., Velasquez, N., Noel, J., Beswick, D. M., Riley, K. O., Patel, Z. M., Cho, D., Dodd, R. L., Thamboo, A., Choby, G. W., Walgama, E., Harsh, G. R., Hwang, P. H., Clemons, L., Lowman, D., Richman, J. S., Woodworth, B. A. 2018

    Abstract

    BACKGROUND: To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing.METHODS: In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases.RESULTS: Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion.CONCLUSION: This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.

    View details for PubMedID 29856526

  • 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

  • Comparison of outcomes following culture-directed vs non-culture-directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis. International forum of allergy & rhinology Yan, C. H., Tangbumrungtham, N., Maul, X. A., Ma, Y., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2018

    Abstract

    BACKGROUND: Acute exacerbations in patients with chronic rhinosinusitis (CRS) are often treated with courses of systemic antibiotics. Poor correlation between microbiologic culture results and the sinus microbiome in CRS has caused increased debate as to the relevance of culture-directed antibiotics. There is currently sparse data comparing outcomes of culture-directed antibiotics vs non-culture-directed antibiotics for treatment of CRS.METHODS: This work reports a retrospective review. A total of 946 CRS patients treated with antibiotics were examined; 122 CRS patients with acute exacerbations were treated with culture-directed (n = 61) vs empiric (n = 61) antibiotics. Lund-Kennedy (LK) and 22-item Sino-Nasal Outcome Test (SNOT-22) scores were compared pretreatment and posttreatment, with short-term (<1 month) and long-term (1-6 months) follow-up. Patient demographics, comorbidities, and prior surgical history were collected.RESULTS: Both groups had similar pretreatment SNOT-22 scores (p = 0.25) while the culture group had higher baseline LK endoscopy scores (p < 0.01). All data were adjusted for pertinent comorbidities, surgical history, co-therapeutics, and baseline scores. There was no difference in improvement in culture-directed and empirically treated groups in the short-term (p = 0.77) and long-term (p = 0.58) for minimal clinically important difference (MCID) of SNOT-22 and no difference in the short-term for LK scores (p = 0.11), but there was significantly more improvement in long-term LK scores in the culture-directed group (p = 0.01).CONCLUSION: Culture-directed therapy improves long-term endoscopy scores but does not yield an advantage in improving short-term endoscopy scores, nor in improving short-term and long-term quality of life scores in CRS patients. A prospective study is necessary to examine the relevance of routine microbiologic cultures in CRS patients.

    View details for PubMedID 29782068

  • Risk Stratification for Postoperative Venous Thromboembolism after Endoscopic Sinus Surgery OTOLARYNGOLOGY-HEAD AND NECK SURGERY Beswick, D. M., Vaezeafshar, R., Ma, Y., Hwang, P. H., Nayak, J. V., Patel, Z. M. 2018; 158 (4): 767–73

    Abstract

    Objectives Venous thromboembolism (VTE) contributes to significant patient morbidity, yet the incidence of VTE following endoscopic sinus surgery (ESS) is unknown. Quality improvement criteria are prompting increased standardization of perioperative VTE prophylaxis. Risk stratification for VTE may better define best practice measures to balance limiting VTE development with avoiding unnecessary chemoprophylaxis. Study Design Retrospective cohort study. Setting Tertiary institution. Subjects and Methods Adult patients who underwent ESS without perioperative chemoprophylaxis from 2008 to 2016 were evaluated. Identification of VTE was performed via screening diagnosis and procedure codes and clinical records, with subsequent confirmation of true-positive VTE. Data for individual Caprini scores were abstracted from electronic medical records. The primary outcome was development of VTE within 30 days following ESS relative to the Caprini score. Results A total of 2369 ESS cases were evaluated. While initial screening identified multiple potential VTE events, in-depth medical record review confirmed only 4 true VTE (0.17%). The VTE rate among cases with a Caprini score of <8 (0.09%, 2/2278) was significantly less ( P = .008) than the rate with a score of ≥8 (2.2%, 2/91). Beyond overall score, specific risk factors associated with development of postoperative VTE included stroke, central venous access, sepsis, and inpatient status (all P < .025), while prior VTE and hypercoagulability were not associated with postoperative VTE (all P > .5). Conclusions In the absence of perioperative chemoprophylaxis, postoperative VTE following ESS is extremely rare, particularly for patients carrying low-to-moderate Caprini scores. Risk stratification based on these data can assist in the design of VTE prophylaxis guidelines for ESS patients.

    View details for PubMedID 29460675

  • Computed tomography analysis of frontal cell prevalence according to the International Frontal Sinus Anatomy Classification. International forum of allergy & rhinology Choby, G., Thamboo, A., Won, T., Kim, J., Shih, L. C., Hwang, P. H. 2018

    Abstract

    BACKGROUND: The International Frontal Sinus Anatomy Classification (IFAC) is an international consensus document published in 2016 to standardize the nomenclature of cells in the region of the frontal recess and frontal sinus. The IFAC was designed to be surgically relevant and anatomically precise. The current study was undertaken to assess the prevalence of the frontal cell variants as defined by the IFAC, as well as to determine the interrater reliability of the IFAC.METHODS: Three independent reviewers examined triplanar nondiseased maxillofacial computed tomography (CT) scans to assess the anatomy of the frontal recess according to the IFAC system. The prevalence of each cell type was assessed and interrater reliability was measured using an intraclass correlation coefficient (ICC).RESULTS: One hundred CT scans (200 sides) were examined. Of the 200 sides, 96.5% contained an agger nasi cell (ICC, 0.82; 95% confidence interval [CI], 0.77-0.86), 30.0% contained a supra agger cell (ICC, 0.89; 95% CI, 0.86-0.92), 20.0% contained a supra agger frontal cell (ICC 0.80; 95% CI 0.74-0.84), 72.0% contained a supra bulla cell (ICC, 0.81; 95% CI, 0.76-0.85), 5.5% contained a supra bulla frontal cell (ICC, 0.71; 95% CI, 0.63-0.77), 28.5% contained a supraorbital ethmoid cell (ICC, 0.78; 95% CI, 0.72-0.83), and 30.0% contained a frontal septal cell (ICC, 0.80; 95% CI, 0.74-0.84). The ICC was good to excellent for identification of all frontal cell types.CONCLUSIONS: This study describes the normative distribution of frontal recess cells in a nondiseased population according to IFAC and demonstrates favorable interrater reliability of the classification system.

    View details for PubMedID 29457874

  • Evolution of the endoscopic modified Lothrop procedure: A systematic review and meta-analysis. The Laryngoscope Shih, L., Patel, V. S., Choby, G. W., Nakayama, T., Hwang, P. H. 2018; 128 (2): 317–26

    Abstract

    OBJECTIVE: Since first described in the 1990s, the endoscopic modified Lothrop procedure (EMLP) has been the subject of a growing body of literature. We performed a review to compare indications and outcomes of EMLP in an early cohort of publications (1990-2008) versus a contemporary cohort (2009-2016) and compare outcomes associated with follow-up ≥2 years versus <2 years.DATA SOURCES: PubMed, SCOPUS and Cochrane databases.REVIEW METHODS: An English-language search of the PubMed and Ovid databases was conducted to identify publications from 1990 to 2016 reporting clinical outcomes of EMLP. Meta-analysis was performed using Statistical Analysis System 9.4.RESULTS: A total of 1,205 patients were abstracted from 29 articles with a mean follow-up of 29.1 ± 10.3 months. The overall rate of significant or complete symptom improvement was 86.5% (95% confidence interval [CI]: 84.2%-88.7%). The overall patency rate was 90.7% (95% CI: 89.1%-92.3%), with a revision rate of 12.6% (95% CI: 10.6%-14.3%). Compared to the early cohort, patients in the contemporary cohort underwent EMLP more often for tumors (P < .001), had higher rates of complete or significant symptom improvement (90.0% vs. 82.6 %, P < .001); and trended toward greater patency rates (92.1% vs. 88.6%, P = .052). Compared to the short-term follow-up cohort, the long-term cohort showed no differences in symptom improvement or patency, but the revision rate was higher (14.5% vs. 9.2%, P = .016).CONCLUSIONS: In the last decade, EMLP has been performed more frequently for tumors. Recent studies have demonstrated improved symptom outcomes and a trend toward improved patency rates. The revision rate increased significantly when follow-up exceeded 2 years. Laryngoscope, 128:317-326, 2018.

    View details for PubMedID 28921539

  • International consensus statement on allergy and rhinology: allergic rhinitis-executive summary INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Wise, S. K., Lin, S. Y., Toskala, E. 2018; 8 (2): 85-107

    Abstract

    The available allergic rhinitis (AR) literature continues to grow. Critical evaluation and understanding of this literature is important to appropriately utilize this knowledge in the care of AR patients. The International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR) has been produced as a multidisciplinary international effort. This Executive Summary highlights and summarizes the findings of the comprehensive ICAR:AR document.The ICAR:AR document was produced using previously described methodology. Specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.Over 100 individual topics related to AR diagnosis, pathophysiology, epidemiology, disease burden, risk factors, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR were addressed in the comprehensive ICAR:AR document. Herein, the Executive Summary provides a synopsis of these findings.In the ICAR:AR critical review of the literature, several strengths were identified. In addition, significant knowledge gaps exist in the AR literature where current practice is not based on the best quality evidence; these should be seen as opportunities for additional research. The ICAR:AR document evaluates the strengths and weaknesses of the AR literature. This Executive Summary condenses these findings into a short summary. The reader is also encouraged to consult the comprehensive ICAR:AR document for a thorough description of this work.

    View details for DOI 10.1002/alr.22070

    View details for Web of Science ID 000424909200002

    View details for PubMedID 29438600

  • Evolution of the Endoscopic Modified Lothrop Procedure: A Systematic Review and Meta-Analysis LARYNGOSCOPE Shih, L., Patel, V. S., Choby, G. W., Nakayama, T., Hwang, P. H. 2018; 128 (2): 317–26

    View details for DOI 10.1002/lary.26794

    View details for Web of Science ID 000422753400014

  • International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Wise, S. K., Lin, S. Y., Toskala, E., Orlandi, R. R., Akdis, C. A., Alt, J. A., Azar, A., Baroody, F. M., Bachert, C., Canonica, G., Chacko, T., Cingi, C., Ciprandi, G., Corey, J., Cox, L. S., Creticos, P., Custovic, A., Damask, C., DeConde, A., DelGaudio, J. M., Ebert, C. S., Eloy, J., Flanagan, C. E., Fokkens, W. J., Franzese, C., Gosepath, J., Halderman, A., Hamilton, R. G., Hoffman, H., Hohlfeld, J. M., Houser, S. M., Hwang, P. H., Incorvaia, C., Jarvis, D., Khalid, A. N., Kilpelaeinen, M., Kingdom, T. T., Krouse, H., Larenas-Linnemann, D., Laury, A. M., Lee, S. E., Levy, J. M., Luong, A. U., Marple, B. F., McCoul, E. D., McMains, K., Melen, E., Mims, J. W., Moscato, G., Mullol, J., Nelson, H. S., Patadia, M., Pawankar, R., Pfaar, O., Platt, M. P., Reisacher, W., Rondon, C., Rudmik, L., Ryan, M., Sastre, J., Schlosser, R. J., Settipane, R. A., Sharma, H. P., Sheikh, A., Smith, T. L., Tantilipikorn, P., Tversky, J. R., Veling, M. C., Wang, D., Westman, M., Wickman, M., Zacharek, M., Andiappan, A., Badorrek, P., Brook, C. D., Campo, P., Chaaban, M. R., Charles-Jones, A., Cheng, E., Chhabra, N., Cox, D., Daraei, P., Drucker, A. M., Fruth, K., Guo, C., Kopp, M., Loftus, P. A., Lopez-Chacon, M., Marino, M. J., Mattos, J., Muluk, N., Ng, C., Nwaru, B. I., Pala, G., Paulin, J., Pfisterer, M., Rosko, A. J., Russo, C., Schuman, T., Segboer, C., Silvestri, M., Smith, K. A., Soyka, M. B., Lujan, J., Thomas, A. J., Viinanen, A., Willson, T. J. 2018; 8 (2): 108–352

    Abstract

    Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

    View details for PubMedID 29438602

  • Early experience with a patient-specific virtual surgical simulation for rehearsal of endoscopic skull-base surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Won, T., Hwang, P., Lim, J., Cho, S., Paek, S., Losorelli, S., Vaisbuch, Y., Chan, S., Salisbury, K., Blevins, N. H. 2018; 8 (1): 54–63

    Abstract

    With the help of contemporary computer technology it is possible to create a virtual surgical environment (VSE) for training. This article describes a patient-specific virtual rhinologic surgical simulation platform that supports rehearsal of endoscopic skull-base surgery. We also share our early experience with select cases.A rhinologic VSE was developed, featuring a highly efficient direct 3-dimensional (3D) volume renderer with simultaneous stereoscopic feedback during surgical manipulation of the virtual anatomy, as well as high-fidelity haptic feedback. We conducted a retrospective analysis on 10 patients who underwent various forms of sinus and ventral skull-base surgery to assess the ability of the rhinologic VSE to replicate actual intraoperative findings.In all 10 cases, the simulation experience was realistic enough to perform dissections in a similar manner as in the actual surgery. Excellent correlation was found in terms of surgical exposure, anatomical features, and the locations of pathology.The current rhinologic VSE shows sufficient realism to allow patient-specific surgical rehearsal of the sinus and ventral skull base. Further validation studies are needed to assess the benefits of performing patient-specific rehearsal.

    View details for PubMedID 29105367

  • Sinonasal debridement versus no debridement for the postoperative care of patients undergoing endoscopic sinus surgery COCHRANE DATABASE OF SYSTEMATIC REVIEWS Tzelnick, S., Alkan, U., Leshno, M., Hwang, P., Soudry, E. 2018: CD011988

    Abstract

    Endoscopic sinus surgery (ESS) is often recommended for symptomatic patients with recurrent acute or chronic rhinosinusitis who have failed conservative treatment. Postoperative care has been felt to be critical for both maintaining the surgical patency of the operated sinuses and improving patient symptoms. Debridement of the sinonasal cavities is one such postoperative care measure that has frequently been studied in the literature, often with conflicting conclusions.To assess the effects of postoperative sinonasal debridement versus no debridement following endoscopic sinus surgery.The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); PubMed; EMBASE; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 May 2018.Randomised controlled trials comparing postoperative nasal debridement versus no debridement in adult patients with recurrent acute or chronic rhinosinusitis undergoing endoscopic sinus surgery. We included studies in which the patients acted as self-controls (i.e. one side of the nose underwent debridement and the other side did not) only for the secondary endoscopy outcomes.We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were: health-related quality of life, disease severity (patient-reported symptom scores) and significant adverse effects (bleeding requiring intervention, severe pain, iatrogenic injury). Secondary outcomes were: postoperative endoscopic appearance of the sinonasal surgical cavities (endoscopic scores), recorded use of postoperative medical treatment and rate of revision surgery. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.We included four studies (152 participants), with a follow-up duration ranging from three months to 12 months. In two studies patients acted as self-controls, i.e. one side of the nose underwent debridement and the other side did not ('split-nose' studies). The risk of bias in all studies was high, mostly due to the inability to blind the patients to the debridement procedure.Primary outcomesDisease-specific health-related quality of life scoresOnly one study (58 participants) provided data for disease-specific health-related quality of life. At six months follow-up, lower disease-specific health-related quality of life scores, measured using the Sino-Nasal Outcome Test-22 (SNOT-22, range 0 to 110), were noted in the debridement group but the difference was not statistically significant (9.7 in the debridement group versus 10.3 in the control group, P = 0.47) (low-quality evidence).Disease severity (patient-reported symptom score)Only one study (60 participants) provided data for disease severity measured by visual analogue scale (VAS) score. No significant differences in total symptom score were observed between groups postoperatively (low-quality evidence).Significant adverse effectsSignificant adverse effects related to the debridement procedure were not reported in any of the included studies, however it is not clear whether data regarding adverse effects were not collected or if none were indeed observed in any of the included studies.Secondary outcomesAll four studies assessed thepostoperative endoscopic appearance of the sinonasal cavities using the Lund-Kennedy score (range 0 to 10). A pooled analysis of endoscopic scores in the two non 'split-nose' studies revealed better endoscopic scores in the debridement group, however this was not a statistically significant difference (mean difference -0.31, 95% confidence interval (CI) -1.35 to 0.72; I² = 0%; two studies; 118 participants) (low-quality evidence). A sub-analysis of the adhesion formation component of the endoscopic score was available for all four studies and revealed a significantly lower adhesion rate in the debridement group (risk ratio 0.43, 95% CI 0.28 to 0.68; I² = 29%; four studies; 152 participants). Analysis of the number needed to treat to benefit revealed that for every three patients undergoing debridement, the endoscopic score would be decreased by one point in one patient. For every five patients undergoing debridement adhesion formation would be prevented in one patient.Use of postoperative medical treatment was reported in all studies, all of which recommended nasal douching. Steroids (systemic or nasal) were administered in two studies. However, the data were very limited and heterogeneous, therefore we could not analyse the impact of concomitant postoperative medical treatment.The rate of revision surgery was not reported in any of the included studies, however it is not clear whether these data were not recorded or if there were no revision surgeries in any of the included studies.We are uncertain about the effects of postoperative sinonasal debridement due to high risk of bias in the included studies and the low quality of the evidence. Sinonasal debridement may make little or no difference to disease-specific health-related quality of life or disease severity. Low-quality evidence suggests that postoperative debridement is associated with a significantly lower risk of adhesions at three months follow-up. Whether this has any impact on longer-term outcomes is unknown.

    View details for DOI 10.1002/14651858.CD011988.pub2

    View details for Web of Science ID 000455159600021

    View details for PubMedID 30407624

  • Outcomes After Endoscopic Endonasal Resection of Craniopharyngiomas in the Pediatric Population WORLD NEUROSURGERY Patel, V. S., Thamboo, A., Quon, J., Nayak, J. V., Hwang, P. H., Edwards, M., Patel, Z. M. 2017; 108: 6–14
  • Comparison of surgical outcomes between patients with unilateral and bilateral chronic rhinosinusitis. International forum of allergy & rhinology Beswick, D. M., Mace, J. C., Chowdhury, N. I., Alt, J. A., Hwang, P. H., DeConde, A. S., Smith, T. L. 2017; 7 (12): 1162-1169

    Abstract

    Although the majority of patients with chronic rhinosinusitis without nasal polyposis (CRSsNP) suffer from bilateral disease, a subset suffer from unilateral disease. Currently, outcomes following endoscopic sinus surgery (ESS) for medically recalcitrant CRS are inferred from outcomes for patients with bilateral disease. This study compares outcomes of ESS between patients with unilateral and bilateral disease.Patients with CRSsNP who failed appropriate medical therapy and elected ESS were enrolled between 2011 and 2015. Patients were dichotomized according to radiographic evidence of unilateral disease (Lund-Mackay [LM] score = 0 for 1 side) or bilateral disease (LM ≥ 1 for both sides). The primary outcome of interest was the 22-item Sino-Nasal Outcome Test (SNOT-22), with secondary outcomes including the Brief Smell Identification Test (BSIT) and the Lund-Kennedy (LK) endoscopy staging system.A total of 190 patients met inclusion criteria consisting of 19 with unilateral (10%) and 171 with bilateral CRSsNP (90%). Both groups were similar across all preoperative demographic factors, SNOT-22, and BSIT scores. Postoperatively, patients with bilateral disease reported greater improvement in mean SNOT-22 scores compared to unilateral disease, but this difference was not statistically or clinically significant (-24.3 ± 21.1 vs -21.5 ± 24.0, p = 0.582). Mean LK scores improved for patients with bilateral disease but not unilateral disease, without a difference between groups (-2.0 ± 3.5 vs -0.4 ± 2.4, p = 0.090).Patients with unilateral CRSsNP experience improvement after ESS comparable to patients with bilateral disease on patient reported outcome measures.

    View details for DOI 10.1002/alr.22020

    View details for PubMedID 28941136

    View details for PubMedCentralID PMC5716933

  • Outcomes After Endoscopic Endonasal Resection of Craniopharyngiomas in the Pediatric Population. World neurosurgery Patel, V. S., Thamboo, A., Quon, J., Nayak, J. V., Hwang, P. H., Edwards, M., Patel, Z. M. 2017; 108: 6-14

    Abstract

    Craniopharyngiomas have traditionally been treated via open transcranial approaches. More recently, endoscopic transsphenoidal approaches have been increasingly used; however, few case series exist in the pediatric population.A retrospective review of patients (aged <18 years) undergoing endoscopic transsphenoidal resection of craniopharyngiomas between 1995 and 2016 was performed. Preoperative data included presenting symptoms, tumor size, location, and components. Postoperative outcomes included symptom resolution, visual outcomes, endocrine outcomes, disease recurrence, and major complications.Sixteen pediatric patients with mean age of 11.0 years (range, 5-15 years) were included. The median follow-up time was 56.2 months. Mean maximal tumor diameter was 3.98 cm. Most of the tumors had suprasellar (93.8%) and intrasellar (68.8%) components. The gross total resection rate was 93.8%. The most common presenting symptoms were vision changes (81.3%) and increased intracranial pressure (56.3%). Most patients (66.7%) had their presenting symptoms resolved by their first postoperative visit. Vision improved or remained normal in 69.2% of patients. Postoperatively, new incidence of panhypopituitarism or diabetes insipidus developed in 63.6% and 46.7% of patients, respectively. New hypothalamic obesity developed in 28.6% of patients. The postoperative cerebrospinal fluid leak rate was 18.8%. One patient died of intraventricular hemorrhage postoperatively. The major complication rate was 12.5%. Disease recurrence occurred in 1 patient with gross total resection (6.3%).Endoscopic transsphenoidal resection for craniopharyngiomas can achieve high rates of total resection with low rates of disease recurrence in larger tumors than previously described. However, hypothalamic-pituitary dysfunction and cerebrospinal fluid leak remain significant postoperative morbidities.

    View details for DOI 10.1016/j.wneu.2017.08.058

    View details for PubMedID 28838874

  • Comparison of surgical outcomes between patients with unilateral and bilateral chronic rhinosinusitis Beswick, D. M., Mace, J. C., Chowdhury, N. I., Alt, J. A., Hwang, P. H., DeConde, A. S., Smith, T. L. WILEY. 2017: 1162–69

    View details for DOI 10.1002/alr.22020

    View details for Web of Science ID 000417284900009

  • Evidence for altered levels of IgD in the nasal airway mucosa of patients with chronic rhinosinusitis JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY Min, J., Nayak, J. V., Hulse, K. E., Stevens, W. W., Raju, P. A., Huang, J. H., Suh, L. A., Van Roey, G. A., Norton, J. E., Carter, R. G., Price, C. E., Weibman, A. R., Rashan, A. R., Ghosn, E. E., Patel, Z. M., Homma, T., Conley, D. B., Welch, K. C., Shintani-Smith, S., Peters, A. T., Grammer, L. C., Harris, K. E., Kato, A., Hwang, P. H., Kern, R. C., Herzenberg, L. A., Schleimer, R. P., Tan, B. K. 2017; 140 (6): 1562-+

    Abstract

    IgD is an enigmatic antibody isotype best known when coexpressed with IgM on naive B cells. However, increased soluble IgD (sIgD) levels and increased IgD+IgM- B-cell populations have been described in the human upper respiratory mucosa.We assessed whether levels of sIgD and IgD+ B cell counts are altered in nasal tissue from patients with chronic rhinosinusitis (CRS). We further characterized IgD+ B-cell populations and explored clinical and local inflammatory factors associated with tissue sIgD levels.sIgD levels were measured by means of ELISA in nasal tissues, nasal lavage fluid, sera, and supernatants of dissociated nasal tissues. IgD+ cells were identified by using immunofluorescence and flow cytometry. Inflammatory mediator levels in tissues were assessed by using real-time PCR and multiplex immunoassays. Bacterial cultures from the middle meatus were performed. Underlying medical history and medicine use were obtained from medical records.sIgD levels and numbers of IgD+ cells were significantly increased in uncinate tissue (UT) of patients with chronic rhinosinusitis without nasal polyps (CRSsNP) compared with that of control subjects (4-fold, P < .05). IgD+ cells were densely scattered in the periglandular regions of UT from patients with CRSsNP. We also found that IgD+CD19+CD38bright plasmablast numbers were significantly increased in tissues from patients with CRSsNP compared with control tissues (P < .05). Among numerous factors tested, IL-2 levels were increased in UT from patients with CRSsNP and were positively correlated with tissue IgD levels. Additionally, supernatants of IL-2-stimulated dissociated tissue from patients with CRSsNP had significantly increased sIgD levels compared with those in IL-2-stimulated dissociated control tissue ex vivo (P < .05). Tissue from patients with CRS with preoperative antibiotic use or those with pathogenic bacteria showed higher IgD levels compared with tissue from patients without these variables (P < .05).sIgD levels and IgD+CD19+CD38bright plasmablast counts were increased in nasal tissue of patients with CRSsNP. IgD levels were associated with increased IL-2 levels and the presence of pathogenic bacteria. These findings suggest that IgD might contribute to enhancement mucosal immunity or inflammation or respond to bacterial infections in patients with CRS, especially CRSsNP.

    View details for PubMedID 28625807

  • Nasoseptal flap closure of the eustachian tube for recalcitrant cerebrospinal fluid rhinorrhea. The Laryngoscope Patel, V. S., Choby, G. W., Thamboo, A., Blevins, N. H., Hwang, P. H. 2017

    View details for PubMedID 29152752

  • Biocompatibility and pharmacokinetics of fluticasone-eluting sinus implant in a rabbit model AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Patel, V. S., Walgama, E., Psaltis, A., Lavigne, F., Pletcher, S. D., Hwang, P. H. 2017; 31 (6): 382–88

    Abstract

    A novel, bioabsorbable, fibrinogen-based implant has been developed as a mucosal dressing after endoscopic sinus surgery (ESS). This implant can be formulated with fluticasone propionate (FP) for local elution of corticosteroid to reduce postoperative inflammation and promote mucosal healing.This study investigated the biocompatibility and pharmacokinetics of the implant in a rabbit model.Implants with and without FP were placed on both intact and demucosalized maxillary sinuses of 33 New Zealand White rabbits. Sinuses with either intact or denuded bone without implants acted as controls. Histopathologic assessments were carried out at 5, 15, and 28 days. Concentrations of FP in the maxillary sinus mucosa, nasal cavity mucosa, and plasma were measured for up to 44 days.Implants placed on intact mucosa or denuded bone were grossly integrated within 15 days. Minimal foreign body reaction was seen with negligible differences for inflammation, fibrosis, or bone remodeling among controls, sinuses with the implant, or sinuses with the implant plus FP, at all time points. All samples also showed complete or near-complete percentage reepithelialization at 28 days, although the denuded bone controls demonstrated greater percentage reepithelialization at 5 days compared with denuded bone with the implant or implant plus FP (p < 0.0001). The maxillary sinus mucosa demonstrated levels of FP of >140 ng/g up to 44 days. Plasma concentrations of FP were generally very low and were undetectable after day 7.The implant and the implant plus FP seemed to be biocompatible in rabbits. The implant plus FP effectively eluted steroid locally over at least 44 days, with negligible plasma concentrations. Further studies are warranted regarding potential therapeutic applications in patients undergoing ESS for chronic rhinosinusitis.

    View details for PubMedID 29122083

  • 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

    Abstract

    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

  • Cryosurgical posterior nasal tissue ablation for the treatment of rhinitis Hwang, P. H., Lin, B., Weiss, R., Atkins, J., Johnson, J. WILEY. 2017: 952–56

    Abstract

    Endoscopic posterior nasal nerve (PNN) resection has been described as an efficacious surgical treatment of allergic and nonallergic rhinitis, but the requirement for surgery under general anesthesia has limited its acceptance. We report the first series of patients treated for chronic rhinitis using a novel device designed for office-based cryosurgical ablation of the PNN.Twenty-seven patients with chronic rhinorrhea and/or nasal congestion for >3 months were recruited (allergic or nonallergic rhinitis), with minimum rhinorrhea and/or congestion subscores of 2 as part of the Total Nasal Symptom Score [TNSS]). Under local anesthesia, the cryotherapy device was applied endoscopically to the posterior middle meatus and was used to freeze the PNN region bilaterally. Patients were followed up after 7, 30, 90, 180, and 365 days to assess TNSS.The procedure was successfully completed in 100% of patients, with no complications; 74% reported no or mild discomfort by the first postprocedure day. TNSS was reduced significantly at 30 days (mean ± standard deviation: 6.2 ± 0.5 at baseline, 2.6 ± 0.3 at 30 days, n = 27, p < 0.001), with continued reduction at 90 (2.7 ± 0.4, n = 24, p < 0.001), 180 (2.3 ± 0.5, n = 21, p < 0.001), and 365 days (1.9 ± 0.3, n = 15, p < 0.001). Both rhinorrhea and congestion subscores decreased significantly at 30, 90, 180, and 365 days compared to baseline (p < 0.001). Allergic and nonallergic subcohorts both appeared to benefit from treatment.Office-based cryotherapy of the PNN region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days.

    View details for PubMedID 28799727

  • 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

    Abstract

    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

  • Pediatric Chronic Rhinosinusitis Management in Rhinologists and Pediatric Otolaryngologists ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY Beswick, D. M., Messner, A. H., Hwang, P. H. 2017; 126 (9): 634–39

    Abstract

    To compare the management of pediatric chronic rhinosinusitis (PCRS) between members of the American Rhinologic Society (ARS) and the American Society of Pediatric Otolaryngology (ASPO).Comparison of surveys.A web-based survey was distributed to ASPO membership twice in September-October 2016. Data were compared to previously published data from ARS membership in March-April 2016.ASPO survey completion rate was 22%. ARS members were more likely to employ oral steroids in initial ( P = .025) and maximal medical management ( P = .001). ASPO members more commonly performed adenoidectomy before computed tomography (CT) ( P < .001). Both groups commonly included adenoidectomy as part of initial surgical management (90% vs 94%, P = .316), while ASPO members more frequently performed adenoidectomy alone (70% vs 43%, P = .001). If initial surgical treatment failed, both groups commonly performed endoscopic sinus surgery (ESS; 81% vs 88%, P = .56) with a similar extent including frontal ( P ≥ .207) and sphenoid ( P ≥ .304) surgery.Pediatric chronic rhinosinusitis management is similar between groups, yet there are differences including oral steroid use, relative order of CT versus adenoidectomy, and performing concomitant procedures with adenoidectomy. Both groups commonly perform ESS with similar surgical extent if prior surgical treatment fails. Management by both groups is largely in agreement with published consensus statements.

    View details for PubMedID 28766959

  • Cavernous Sinus Involvement by Pituitary Adenomas: Clinical Implications and Outcomes of Endoscopic Endonasal Resection JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Ajlan, A., Achrol, A. S., Albakr, A., Feroze, A. H., Westbroek, E. M., Hwang, P., Harsh, G. R. 2017; 78 (3): 273–81

    Abstract

    Background  Parasellar invasion of pituitary adenomas (PAs) into the cavernous sinus (CS) is common. The management of the CS component of PA remains controversial. Objective  The objective of this study was to analyze CS involvement in PA treated with endoscopic endonasal approaches, including incidence, surgical risks, surgical strategies, long-term outcomes, and our treatment algorithm. Methods  We reviewed a series of 176 surgically treated PA with particular attention to CS involvement and whether the CS tumor was approached medial or lateral to the internal carotid artery. Results  The median duration of follow-up was 36 months. Macroadenomas and nonfunctional adenomas represented 77 and 60% of cases, respectively. CS invasion was documented in 23% of cases. CS involvement was associated with a significantly diminished odds of gross total resection (47 vs. 86%, odds ratio [OR]: 5.2) and increased the need for subsequent intervention (4 vs. 40%, OR: 14.4). Hormonal remission was achieved in 15% of hormonally active tumors. Rates of surgical complication were similar regardless of CS involvement. Conclusion  Our tailored strategy beginning with a medial approach and adding lateral exposure as needed resulted in good outcomes with low morbidity in nonfunctional adenomas. Functional adenomas involving the CS were associated with low rates of hormonal remission necessitating higher rates of additional treatment.

    View details for PubMedID 28603683

    View details for PubMedCentralID PMC5463411

  • Emerging Roles of Coblation in Rhinology and Skull Base Surgery. Otolaryngologic clinics of North America Choby, G. W., Hwang, P. H. 2017; 50 (3): 599-606

    Abstract

    Coblation is a technology that incorporates bipolar radiofrequency energy to ablate tissue at relatively low temperatures. Its use for sinonasal surgery is actively being investigated, including applications for turbinate reduction, sinus surgery, skull base surgery, and adenoidectomy. Potential benefits include reduction in blood loss, improved endoscopic surgical visualization, and reduction in postoperative pain. The main drawbacks are its relatively high cost, potential adverse effects on functional epithelium, and relative paucity of long-term outcomes.

    View details for DOI 10.1016/j.otc.2017.01.010

    View details for PubMedID 28325634

  • Central Serous Chorioretinopathy after Endoscopic Sinus Surgery OTOLARYNGOLOGY-HEAD AND NECK SURGERY Woo, H., Hwang, P. H. 2017; 156 (4): 772–73

    View details for PubMedID 28195007

  • Selective expansion of human regulatory T cells in nasal polyps, and not adjacent tissue microenvironments, in individual patients exposed to steroids. Clinical immunology Edward, J. A., Sanyal, M., Le, W., Soudry, E., Ramakrishnan, V. R., Bravo, D. T., Nguyen, A. L., Zarabanda, D., Kingdom, T. T., Hwang, P. H., Garrison Fathman, C., Nayak, J. V. 2017; 179: 66-76

    Abstract

    Severe forms of chronic rhinosinusitis (CRS), a common upper airway inflammatory disorder, are associated with nasal polyps (NPs). NP disease is ameliorated by glucocorticoid (GC) treatment, whose cellular effects are poorly understood. We therefore assessed the influence of GC therapy on NPs in CRS patients, focusing on regulatory T (Treg) cells. Treg cell populations were analyzed by flow cytometry in NPs and control tissues from GC-treated CRS patients and controls. After GC exposure, selective expansion of Treg cells was seen within NPs, and not blood or adjacent ethmoid tissues. To confirm direct GC effects, NPs from the same patients were biopsied prior to, and following, 1week of oral GC exposure. Direct expansion of Tregs into the same NP bed was detected in 4/4 CRS patients following GC exposure. Treg cell spikes into NPs were secondary to cellular recruitment given limited Ki67 expression within these regulatory cells. Chemokine gene expression profiling identified several chemokines, notably CCL4, induced within NPs upon GC treatment. Neutralization of chemokine receptor/ligand interactions using CCR4 small molecule antagonists reduced Treg migration towards GC-treated NPs in an ex vivo migration assay. Our findings suggest that the common use of GCs in the treatment of NP disease leads to recruitment of Treg cells from peripheral sites into NP tissues, which may be critical to the anti-inflammatory effect of GCs. Mechanistically Treg expansion appears to be conferred, in part, by chemokine receptor/ligand interactions induced following corticosteroid therapy.

    View details for DOI 10.1016/j.clim.2017.02.002

    View details for PubMedID 28279811

  • Impact of endoscopic sinus surgery on otologic symptoms associated with chronic rhinosinusitis. World journal of otorhinolaryngology - head and neck surgery Teo, N. W., Mace, J. C., Smith, T. L., Hwang, P. H. 2017; 3 (1): 24–31

    Abstract

    OBJECTIVE: To evaluate improvements in otologic symptoms after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS), and identify differences in symptoms, if any, between CRS patients with (CRSwNP) and without (CRSsNP) nasal polyposis.STUDY DESIGN: Prospective multi-center observational cohort study.SETTING: Academic tertiary medical centers.SUBJECTS AND METHODS: Adults with medically recalcitrant CRS who elected ESS were enrolled in a prospective, multi-center, observational cohort study between March, 2011 and October, 2014. Preoperative evaluation of subjects included assessment of clinical characteristics, measures of disease severity, and quality of life evaluation using the 22-item SinoNasal Outcome Test (SNOT-22). Postoperative improvement in otologic symptoms (ear fullness, dizziness, ear pain) scores were evaluated and compared between CRSwNP and CRSsNP subgroups.RESULTS: 395 study patients completed both preoperative and postoperative evaluations, with an average follow-up of 13.9 months after ESS. The prevalence of patients reporting at least one otologic symptom preoperatively (87%) significantly decreased after ESS (63%; p<0.001). Significant postoperative improvement across all otologic scores was also reported (p<0.001). Relative mean improvement in otologic symptom severity was similar for both CRSwNP and CRSsNP, except patients with CRSwNP reported significantly greater postoperative improvement in ear fullness compared to CRSsNP (54% vs. 41%; p=0.039). A total of 61%, 44%, and 43% of patients reported experiencing improvement in "ear fullness", "dizziness" and "ear pain", respectively.CONCLUSION: Sinus surgery significantly improves otologic symptoms associated with CRS. CRSwNP patients reported slightly greater relief of ear fullness than CRSsNP patients following ESS.

    View details for PubMedID 28990012

  • 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

    Abstract

    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

  • Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis. International forum of allergy & rhinology Patel, Z. M., Thamboo, A., Rudmik, L., Nayak, J. V., Smith, T. L., Hwang, P. H. 2017; 7 (2): 119-127

    Abstract

    The currently accepted treatment paradigm of treating chronic rhinosinusitis (CRS) first with appropriate medical therapy (AMT) and then with surgery if patients are refractory to AMT, has been criticized for lack of evidence. The objective of this study was to reassess the literature and establish the highest level of evidence possible regarding further management of CRS patients refractory to AMT.This study was a systematic review (SR) with meta-analysis (MA). Adult CRS patients who received AMT and then underwent either medical or surgical therapy in moderate to high level prospective studies were included. Outcomes assessed were disease-specific quality of life (QOL), nasal endoscopy, health-state utility, missed work days, change in cardinal symptoms of CRS, economic impact, and adverse events.A total of 970 manuscripts were identified; 6 studies were ultimately included in the SR with 5 included in the MA. Compared to continued medical therapy, endoscopic sinus surgery (ESS) significantly improved patient-based QOL scores (p < 0.00001) and nasal endoscopy scores (p < 0.00001). Difference in missed work days depended heavily on patient choice of intervention. Unpooled analysis showed improvements in olfaction, health utility scores, and cost-effectiveness.On meta-analysis, for CRS patients refractory to AMT, ESS significantly improves objective endoscopic scoring outcomes vs continued medical therapy alone. In patients with refractory CRS who have significant reductions in baseline QOL, ESS results in significant improvements. Continued medical therapy appears to maintain outcomes in patients with less severe baseline QOL. Unpooled analysis demonstrates improvement in health utility, olfaction, and cost-effectiveness following ESS compared to continued medical therapy alone, in medically refractory CRS.

    View details for DOI 10.1002/alr.21872

    View details for PubMedID 27863163

  • Aspirin-Exacerbated Respiratory Disease OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Walgama, E. S., Hwang, P. H. 2017; 50 (1): 83-?

    Abstract

    Aspirin-exacerbated respiratory disease (AERD) is characterized by the triad of asthma, sinonasal polyposis, and aspirin intolerance. The hallmark of the disease is baseline overproduction of cysteinyl leukotrienes via the 5-lipoxygenase pathway, exacerbated by ingestion of aspirin. Patients with AERD have high rates of recidivistic polyposis following sinus surgery, although the improvement in quality of life following surgery is similar to aspirin-tolerant patients. The diagnosis is secured by a positive aspirin provocation test, usually administered by a medical allergist. Aspirin therapy is a unique treatment consideration for patients with AERD.

    View details for DOI 10.1016/j.otc.2016.08.007

    View details for Web of Science ID 000390983700008

    View details for PubMedID 27888917

  • Comparing Surgeon Outcomes in Endoscopic Sinus Surgery for Chronic Rhinosinusitis LARYNGOSCOPE Smith, T. L., Mace, J. C., Rudmik, L., Schlosser, R. J., Hwang, P. H., Alt, J. A., Soler, Z. M. 2017; 127 (1): 14-21

    Abstract

    The objective of this investigation was to evaluate endoscopic sinus surgery (ESS) outcomes for chronic rhinosinusitis (CRS) between medical centers to determine if differences in quality-of-life outcomes were detectable. In addition, we sought to identify significant, independent cofactors toward the development of an ESS-specific risk-adjustment model so that ESS outcomes may be appropriately compared between institutions and healthcare providers.Prospective, multicenter, observational cohort.Study participants electing ESS for CRS were enrolled and randomly selected in equal numbers from three academic clinical practices in North America between April 2011 and May 2015. The magnitude of average 6-month postoperative improvement in patient-related outcome measures (PROMs) was compared between enrollment sites using multivariate linear regression modeling.A total of 228 participants met inclusion criteria and were included for final analyses (n = 76 per site). The prevalence of septal deviation/septoplasty and oral corticosteroid-dependent conditions was significantly different between enrollment sites (P ≤ 0.004). Each enrollment site generated significant within-subject improvement across all PROMs after ESS (P < 0.001); however, average unadjusted magnitudes of improvement were significantly different between sites for the primary outcome measure. After controlling for baseline PROMs, septal deviation, steroid-dependent conditions, and medication use variables, enrollment site was no longer associated with significant outcome differences (P = 0.535).Comparison of surgeon outcomes of ESS is feasible and must take into account a number of baseline patient characteristics. Further studies will be critical toward developing an ESS-specific risk-adjustment model and enabling a robust comparison of surgeon outcomes.2c. Laryngoscope, 127:14-21, 2017.

    View details for DOI 10.1002/lary.26095

    View details for Web of Science ID 000394951400017

    View details for PubMedCentralID PMC5156587

  • Endoscopic vs. Microscopic Resection of Sellar Lesions-A Matched Analysis of Clinical and Socioeconomic Outcomes. Frontiers in surgery Azad, T. D., Lee, Y. J., Vail, D. n., Veeravagu, A. n., Hwang, P. H., Ratliff, J. K., Li, G. n. 2017; 4: 33

    Abstract

    Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages.To determine if the proposed benefits of endoscopic resection are realized on a population level.We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions. Coarsened matching was applied to estimate the effects of surgical approach on complication rates, length of stay (LOS), costs, and likelihood of postoperative radiation.We found that LOS, readmission, and revision rates did not differ significantly between approaches. The overall complication rate was higher for endoscopy (47% compared to 39%, OR 1.37, 95% CI 1.22-1.53). Endoscopic approach was associated with greater risk of neurological complications (OR 1.32, 95% CI 1.11-1.55), diabetes insipidus (OR 1.65, 95% CI 1.37-2.00), and cerebrospinal fluid rhinorrhea (OR 1.83, 95% CI 1.07-3.13) compared to the microscopic approach. Although the total index payment was higher for patients receiving endoscopic resection ($32,959 compared to $29,977 for microscopic resection), there was no difference in long-term payments. Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery (OR 0.67, 95% CI 0.49-0.90) and intensity-modulated radiation therapy (OR 0.78, 95% CI 0.65-0.93).Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation. Although there are evident advantages to transsphenoidal endoscopy, our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.

    View details for PubMedID 28691009

  • Silicone Oil-Induced Nasal Polyposis: A Case Report. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Patel, V. S., Hwang, P. H., Kossler, A. L., Choby, G. n. 2017: 194599817728896

    View details for PubMedID 28871877

  • 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

    Abstract

    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

  • Equivalence in outcomes between Draf 2B vs Draf 3 frontal sinusotomy for refractory chronic frontal rhinosinusitis. International forum of allergy & rhinology Patel, V. S., Choby, G. n., Shih, L. C., Patel, Z. M., Nayak, J. V., Hwang, P. H. 2017

    Abstract

    Endoscopic Draf 2B and Draf 3 frontal sinusotomies are frequently performed for chronic refractory frontal rhinosinusitis. The purpose of this study was to compare outcomes between Draf 2B and Draf 3 procedures.A retrospective cohort study was conducted comparing patients undergoing bilateral Draf 2B vs Draf 3 procedures from 2000 to 2016. Patients with neoplasia, dysplasia, mucocele, cystic fibrosis, or ciliary dyskinesia were excluded. Preoperative disease parameters included number of prior surgeries, presence of polyps, preoperative 22-item Sino-Nasal Outcome Test (SNOT-22) score, frontal Lund-Mackay score, anterior-posterior diameter of the frontal ostium, and Global Osteitis Scoring Scale (GOSS). Postoperative outcomes included SNOT-22 score, neo-ostium patency, surgical revision rates, and complications.A total of 21 patients with bilateral Draf 2B and 17 patients with Draf 3 surgeries were compared. Mean follow-up time was 15.6 months. No significant differences were seen between groups for any preoperative disease parameter. Both cohorts showed statistically significant (p = 0.0001 [Draf 2B]; p = 0.0001 [Draf 3]) and clinically meaningful (Δ = 24.1; Δ = 24.9) improvements in SNOT-22 at last follow-up vs preoperatively. The Draf 2B group had greater improvement in SNOT-22 score than the Draf 3 group at 1 to 3 months (p = 0.003), but the magnitude of improvement equalized at 5 to 9 months (p = 0.66) and last follow-up (p = 0.90). No significant differences were noted between groups regarding patency, revision rates, or complications.Both Draf 2B and Draf 3 procedures offer durable symptomatic improvement for patients with refractory frontal CRS. The Draf 2B is associated with earlier postoperative symptom improvement and overall shows comparable long-term outcomes to the Draf 3 sinusotomy.

    View details for PubMedID 29131540

  • The prevalence of Eustachian tube dysfunction symptoms in patients with chronic rhinosinusitis. International forum of allergy & rhinology Tangbumrungtham, N. n., Patel, V. S., Thamboo, A. n., Patel, Z. M., Nayak, J. V., Ma, Y. n., Choby, G. n., Hwang, P. H. 2017

    Abstract

    While Eustachian tube dysfunction (ETD) is a known comorbidity of chronic rhinosinusitis (CRS), the prevalence of ETD symptoms in the CRS population is poorly understood. We sought to determine the cross-sectional prevalence of ETD in patients with CRS using the validated Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and to correlate ETDQ-7 scores with 22-item Sino-Nasal Outcome Test (SNOT-22) scores, endoscopy scores, and computed tomography (CT) scores.A total of 101 patients with confirmed CRS completed the ETDQ-7 and SNOT-22 at their initial visit to our rhinology clinic. Lund-Mackay CT and Lund-Kennedy endoscopy scores were also obtained. Spearman's correlation coefficient (ρ) was calculated.Among the 101 patients, 49 patients (48.5%) had an ETDQ-7 score of ≥14.5, signifying clinically significant ETD. The mean ± standard deviation (SD) ETDQ-7 score of the entire cohort was 17.8 ± 10.1. There was a moderately strong correlation between ETDQ-7 and the SNOT-22 ear subdomain (ρ = 0.691, p < 0.001). The correlation coefficient between ETDQ-7 and total SNOT-22 scores was ρ = 0.491 (p < 0.001), indicating moderate correlation. ETDQ-7 scores were poorly correlated to objective measures of sinonasal disease, including Lund-Mackay CT score (ρ = -0.055, p = 0.594) and Lund-Kennedy endoscopy score (ρ = -0.099, p = 0.334).Symptoms of ETD are highly prevalent among patients with CRS as documented by patient-reported outcome measures. The correlation between ETDQ-7 scores and SNOT-22 ear subdomain scores is moderately strong, while the correlation between ETDQ-7 scores and SNOT-22 scores is moderate. ETD severity does not correlate with CT score or nasal endoscopy score.

    View details for PubMedID 29227048

  • Practice patterns in pediatric chronic rhinosinusitis: A survey of the American Rhinologic Society AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Beswick, D. M., Ramadan, H., Baroody, F. M., Hwang, P. H. 2016; 30 (6): 418-423

    Abstract

    The management of pediatric chronic rhinosinusitis (PCRS) is evolving.To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS.A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership.The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD.Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.

    View details for DOI 10.2500/ajra.2016.30.4373

    View details for Web of Science ID 000390857000015

    View details for PubMedID 28124653

  • Response to: The "RACE" national database for recurrent acute rhinosinusitis may need a relook INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Jacobs, J., Bleier, B. S., Hopkins, C., Hwang, P., Poetker, D., Schlosser, R., Stewart, M., Varshney, R. 2016; 6 (10): 1100

    View details for PubMedID 27383827

  • Design and rationale of a prospective, multi-institutional registry for patients with sinonasal malignancy. Laryngoscope Beswick, D. M., Holsinger, F. C., Kaplan, M. J., Fischbein, N. J., Hara, W., Colevas, A. D., Le, Q., Berry, G. J., Hwang, P. H. 2016; 126 (9): 1977-1980

    Abstract

    Assessment of patients with sinonasal malignancy is challenging due to the low disease incidence and diverse histopathology. The current literature is composed mainly of retrospective studies with heterogeneous cohorts, and the rarity of cases limits our understanding of disease characteristics and treatment outcomes. We describe the development of a prospective, multi-institutional registry that utilizes cloud-based computing to evaluate treatment outcomes in patients with sinonasal cancer.A web-based, secure database was built to prospectively capture longitudinal outcomes and quality-of-life (QoL) data in patients diagnosed with sinonasal malignancy. Demographics, tumor staging, and treatment outcomes data are being collected. The Sinonasal Outcome Test-22 and University of Washington Quality of Life Questionnaire are administered at presentation and at recurring intervals. To date, seven institutions are participating nationally.This prospective, multi-institutional registry will provide novel oncological and QoL outcomes on patients with sinonasal malignancy to inform management decisions and disease prognostication. The application of cloud-based computing facilitates secure multi-institutional collaboration and may serve as a model for future registry development for the study of rare diseases in otolaryngology.2C. Laryngoscope, 2016.

    View details for DOI 10.1002/lary.25996

    View details for PubMedID 27283472

  • The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery (EFSS) INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Wormald, P., Hoseman, W., Callejas, C., Weber, R. K., Kennedy, D. W., Citardi, M. J., Senior, B. A., Smith, T. L., Hwang, P. H., Orlandi, R. R., Kaschke, O., Siow, J. K., Szczygielski, K., Goessler, U., Khan, M., Bernal-Sprekelsen, M., Kuehnel, T., Psaltis, A. 2016; 6 (7): 677-696

    Abstract

    The frontal recess and frontal sinus anatomy can vary from simple to complex. The variations in the anatomy of the frontal recess and frontal sinus are considerable but almost all variations can be classified if the various cell patterns are analyzed. This consensus document was developed to improve the ability of the surgeon to understand these possible variations, plan the surgery, and communicate these complexities when teaching or reporting outcomes. Once the surgeon understands the anatomical pattern of the frontal sinus and recess cells, the extent of surgery can be planned. This document presents a classification of the extent of surgery based on the anatomical classification.

    View details for DOI 10.1002/alr.21738

    View details for PubMedID 26991922

  • Comparing surgeon outcomes in endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope Smith, T. L., Mace, J. C., Rudmik, L., Schlosser, R. J., Hwang, P. H., Alt, J. A., Soler, Z. M. 2016

    Abstract

    The objective of this investigation was to evaluate endoscopic sinus surgery (ESS) outcomes for chronic rhinosinusitis (CRS) between medical centers to determine if differences in quality-of-life outcomes were detectable. In addition, we sought to identify significant, independent cofactors toward the development of an ESS-specific risk-adjustment model so that ESS outcomes may be appropriately compared between institutions and healthcare providers.Prospective, multicenter, observational cohort.Study participants electing ESS for CRS were enrolled and randomly selected in equal numbers from three academic clinical practices in North America between April 2011 and May 2015. The magnitude of average 6-month postoperative improvement in patient-related outcome measures (PROMs) was compared between enrollment sites using multivariate linear regression modeling.A total of 228 participants met inclusion criteria and were included for final analyses (n = 76 per site). The prevalence of septal deviation/septoplasty and oral corticosteroid-dependent conditions was significantly different between enrollment sites (P ≤ 0.004). Each enrollment site generated significant within-subject improvement across all PROMs after ESS (P < 0.001); however, average unadjusted magnitudes of improvement were significantly different between sites for the primary outcome measure. After controlling for baseline PROMs, septal deviation, steroid-dependent conditions, and medication use variables, enrollment site was no longer associated with significant outcome differences (P = 0.535).Comparison of surgeon outcomes of ESS is feasible and must take into account a number of baseline patient characteristics. Further studies will be critical toward developing an ESS-specific risk-adjustment model and enabling a robust comparison of surgeon outcomes.2c. Laryngoscope, 127:14-21, 2017.

    View details for DOI 10.1002/lary.26095

    View details for PubMedID 27298069

  • Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations RHINOLOGY Lal, D., Jategaonkar, A. A., Borish, L., Chambliss, L. R., Gnagi, S. H., Hwang, P. H., Rank, M. A., Stankiewicf, J. A., Lund, V. J. 2016; 54 (2): 99-104

    Abstract

    Management of rhinosinusitis during pregnancy requires special considerations.1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations.The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea.Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations.The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.

    View details for DOI 10.4193/Rhino15.228

    View details for Web of Science ID 000378015400002

    View details for PubMedID 26800862

  • Safety analysis of long-term budesonide nasal irrigations in patients with chronic rhinosinusitis post endoscopic sinus surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Soudry, E., Wang, J., Vaezeafshar, R., Katznelson, L., Hwang, P. H. 2016; 6 (6): 568-572

    Abstract

    Although the safety of topical nasal steroids is well established for nasal spray forms, data regarding the safety of steroid irrigations is limited. We studied the effect of long-term budesonide nasal irrigations (>6 months) on hypothalamic-pituitary-adrenal axis (HPAA) function and intraocular pressure (IOP) in patients post-endoscopic sinus surgery.This was retrospective case series. Adrenal function was assessed by using the high-dose cosyntropin stimulation test.A total of 48 patients were assessed, with a mean duration of budesonide irrigations of 22 months. Stimulated cortisol levels were abnormally low in 11 patients (23%). None reported to have symptoms of adrenal suppression. Three of 4 patients who repeated the study being off budesonide for at least 1 month returned to near normal levels. Logistic regression analysis revealed that concomitant use of both nasal steroid sprays and pulmonary steroid inhalers was significantly associated with HPAA suppression (p = 0.024). Patients with low stimulated cortisol levels were able to continue budesonide irrigations under the supervision of an endocrinologist without frank clinical manifestations of adrenal insufficiency. IOP was within normal limits in all patients.Long-term use of budesonide nasal irrigations is generally safe, but asymptomatic HPAA suppression may occur in selected patients. Concomitant use of both nasal steroid sprays and pulmonary steroid inhalers while using daily budesonide nasal irrigations is associated with an increased risk. Rhinologists should be alerted to the potential risks of long-term use of budesonide nasal irrigations, and monitoring for HPAA suppression may be warranted in patients receiving long-term budesonide irrigation therapy.

    View details for DOI 10.1002/alr.21724

    View details for Web of Science ID 000379700700003

    View details for PubMedID 26879335

  • Outcomes of chronic frontal sinusitis treated with ethmoidectomy: a prospective study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Abuzeid, W. M., Mace, J. C., Costa, M. L., Rudmik, L., Soler, Z. M., Kim, G. S., Smith, T. L., Hwang, P. H. 2016; 6 (6): 597-604

    Abstract

    In medically refractory chronic frontal sinusitis, ethmoidectomy without instrumentation of the frontal ostium may resolve frontal disease. Our aim was to determine the efficacy of ethmoidectomy alone for the treatment of chronic frontal sinusitis.Adults with chronic rhinosinusitis prospectively enrolled in a multicenter study who demonstrated frontal sinusitis on computed tomography were divided into 2 groups: (1) endoscopic sinus surgery (ESS) incorporating ethmoidectomy, but excluding frontal sinusotomy; and (2) ESS incorporating frontal sinusotomy. The primary outcome was improvement in 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Secondary outcomes included endoscopic scores and use of corticosteroids and antibiotics.A total of 196 cases undergoing frontal sinusotomy and 30 cases treated with ethmoidectomy without frontal sinusotomy were analyzed and were comparable demographically. The prevalence of nasal polyps, previous ESS, asthma, and aspirin intolerance was more common in the frontal sinusotomy group (p < 0.050). Preoperative endoscopy and computed tomography scores were higher in the frontal sinusotomy group (p ≤ 0.001). Postoperatively, both groups showed comparable SNOT-22 scores with worse endoscopy scores in the frontal sinusotomy group (p = 0.038). Postoperative improvement in SNOT-22 total and subdomain scores was comparable between groups. Nasal endoscopy scores improved to a greater degree in the frontal sinusotomy group (p = 0.023). Duration of postoperative topical steroid use was higher in the frontal sinusotomy group (p = 0.007). Revision surgery was needed in 2.6% of frontal sinusotomy patients and 0% of patients without frontal sinusotomy.The treatment of chronic frontal sinusitis through ethmoidectomy is a potential alternative to frontal sinusotomy achieving similar quality of life (QOL) improvements in patients manifesting less severe sinus disease.

    View details for DOI 10.1002/alr.21726

    View details for PubMedID 26879467

  • Productivity costs decrease after endoscopic sinus surgery for refractory chronic rhinosinusitis. Laryngoscope Rudmik, L., Smith, T. L., Mace, J. C., Schlosser, R. J., Hwang, P. H., Soler, Z. M. 2016; 126 (3): 570-574

    Abstract

    The primary objective of this pilot study was to define the change in productivity costs following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Secondary objectives were to identify CRS-related characteristics that may influence the degree of productivity improvement after ESS.Prospective, multi-institutional, observational cohort study.The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time were quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 US Census and the 2013 US Department of Labor statistics.Twenty-seven patients with refractory CRS who underwent ESS were followed for a mean of 15 months (range, 8-25 months). Following ESS, there were improvements in annual absenteeism (22 days reduced to 3 days), annual presenteeism (41 days reduced to 19 days), and annual household days lost (12 days reduced to 6 days). Overall, the preoperative productivity costs were reduced after ESS ($9,190 vs. $3,373, respectively; P < .001).Daily productivity is negatively impacted by the presence of CRS. The outcomes from this study provide the first insights into the reduced productivity costs associated with receiving ESS for refractory CRS. Future studies with larger sample sizes will need to validate the results from this pilot study.2c Laryngoscope, 126:570-574, 2016.

    View details for DOI 10.1002/lary.25656

    View details for PubMedID 26371457

  • International Consensus Statement on Allergy and Rhinology: Rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Orlandi, R. R., Kingdom, T. T., Hwang, P. H., Smith, T. L., Alt, J. A., Baroody, F. M., Batra, P. S., Bernal-Sprekelsen, M., Bhattacharyya, N., Chandra, R. K., Chiu, A., Citardi, M. J., Cohen, N. A., DelGaudio, J., Desrosiers, M., Dhong, H., Douglas, R., Ferguson, B., Fokkens, W. J., Georgalas, C., Goldberg, A., Gosepath, J., Hamilos, D. L., Han, J. K., Harvey, R., Hellings, P., Hopkins, C., Jankowski, R., Javer, A. R., Kern, R., Kountakis, S., Kowalski, M. L., Lane, A., Lanza, D. C., Lebowitz, R., Lee, H., Lin, S. Y., Lund, V., Luong, A., Mann, W., Marple, B. F., McMains, K. C., Metson, R., Naclerio, R., Nayak, J. V., Otori, N., Palmer, J. N., Parikh, S. R., Passali, D., Peters, A., Piccirillo, J., Poetker, D. M., Psaltis, A. J., Ramadan, H. H., Ramakrishnan, V. R., Riechelmann, H., Roh, H., Rudmik, L., Sacks, R., Schlosser, R. J., Senior, B. A., Sindwani, R., Stankiewicz, J. A., Stewart, M., Tan, B. K., Toskala, E., Voegels, R., Wang, D. Y., Weitzel, E. K., Wise, S., Woodworth, B. A., Wormald, P., Wright, E. D., Zhou, B., Kennedy, D. W. 2016; 6: S22-S209

    Abstract

    Isam Alobid, MD, PhD(1) , Nithin D. Adappa, MD(2) , Henry P. Barham, MD(3) , Thiago Bezerra, MD(4) , Nadieska Caballero, MD(5) , Eugene G. Chang, MD(6) , Gaurav Chawdhary, MD(7) , Philip Chen, MD(8) , John P. Dahl, MD, PhD(9) , Anthony Del Signore, MD(10) , Carrie Flanagan, MD(11) , Daniel N. Frank, PhD(12) , Kai Fruth, MD, PhD(13) , Anne Getz, MD(14) , Samuel Greig, MD(15) , Elisa A. Illing, MD(16) , David W. Jang, MD(17) , Yong Gi Jung, MD(18) , Sammy Khalili, MD, MSc(19) , Cristobal Langdon, MD(20) , Kent Lam, MD(21) , Stella Lee, MD(22) , Seth Lieberman, MD(23) , Patricia Loftus, MD(24) , Luis Macias-Valle, MD(25) , R. Peter Manes, MD(26) , Jill Mazza, MD(27) , Leandra Mfuna, MD(28) , David Morrissey, MD(29) , Sue Jean Mun, MD(30) , Jonathan B. Overdevest, MD, PhD(31) , Jayant M. Pinto, MD(32) , Jain Ravi, MD(33) , Douglas Reh, MD(34) , Peta L. Sacks, MD(35) , Michael H. Saste, MD(36) , John Schneider, MD, MA(37) , Ahmad R. Sedaghat, MD, PhD(38) , Zachary M. Soler, MD(39) , Neville Teo, MD(40) , Kota Wada, MD(41) , Kevin Welch, MD(42) , Troy D. Woodard, MD(43) , Alan Workman(44) , Yi Chen Zhao, MD(45) , David Zopf, MD(46) CONTRIBUTING AUTHOR AFFILIATIONS: (1) Universidad de Barcelona; (2) University of Pennsylvania; (3) Louisiana State University Health Sciences Center; (4) Universidade de São Paulo; (5) ENT Specialists of Illinois; (6) University of Arizona; (7) University of Oxford; (8) University of Texas; (9) University of Indiana; (10) Mount Sinai Beth Israel; (11) Emory University; (12) University of Colorado; (13) Wiesbaden, Germany; (14) University of Colorado; (15) University of Alberta; (16) University of Alabama at Birmingham; (17) Duke University; (18) Sungkyunkwan University; (19) University of Pennsylvania; (20) Universidad de Barcelona; (21) Northwestern University; (22) University of Pittsburgh; (23) New York University; (24) Emory University; (25) University of British Columbia; (26) Yale University School of Medicine; (27) Private Practice; (28) Department of Otolaryngology, Hôtel-Dieu Hospital, Centre de Recherche du Centre Hospitalier de l'Université de Montréal; (29) University of Adelaide; (30) Pusan National University; (31) University of California, San Francisco; (32) University of Chicago; (33) University of Auckland; (34) Johns Hopkins University; (35) University of New South Wales, Australia; (36) Stanford University; (37) Washington University; (38) Harvard Medical School; (39) Medical University of South Carolina; (40) Singapore General Hospital; (41) Taho University; (42) Northwestern University; (43) Cleveland Clinic Foundation; (44) University of Pennsylvania; (45) University of Adelaide; (46) University of Michigan.

    View details for DOI 10.1002/alr.21695

    View details for PubMedID 26889651

  • International Consensus Statement on Allergy and Rhinology: Rhinosinusitis Executive Summary. International forum of allergy & rhinology Orlandi, R. R., Kingdom, T. T., Hwang, P. H. 2016; 6: S3-S21

    Abstract

    The body of knowledge regarding rhinosinusitis (RS) continues to expand, with rapid growth in number of publications yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). This executive summary consolidates the findings of the ICAR:RS document.ICAR:RS presents over 140 topics in the forms of evidence-based reviews with recommendations (EBRRs) and evidence-based reviews (EBR). The structured recommendations of the EBRR sections are summarized in this executive summary.This summary compiles the EBRRs regarding medical and surgical management of acute RS (ARS) and chronic RS with and without nasal polyps (CRSwNP and CRSsNP).This ICAR:RS Executive Summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

    View details for DOI 10.1002/alr.21694

    View details for PubMedID 26878819

  • Indications and outcomes for Draf IIB frontal sinus surgery AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Turner, J. H., Vaezeafshar, R., Hwang, P. H. 2016; 30 (1): 70-73

    Abstract

    Extended frontal surgery techniques are often required when maximal medical therapy and standard endoscopic surgical approaches fail in patients. Although outcomes of the Draf III (modified Lothrop) procedure have been widely reported, postoperative outcomes and indications for the Draf IIB frontal sinusotomy have been relatively underreported. We presented our institution's experience with the Draf IIB procedure.Patients who underwent the Draf IIB frontal sinusotomy between 2007 and 2012 were identified by retrospective chart review. Data collected included demographics, imaging, sinus patency, and Sino-nasal Outcome Test 20 scores.A total of 22 Draf IIB frontal sinusotomies were performed in 18 patients. Thirteen of eighteen patients had previous frontal sinus surgery. The most common indications for the extended approach were chronic frontal sinusitis due to lateralized middle turbinate remnant (8 patients), mucocele (6), postoperative synechiae (5), and frontal sinus mass (3). Sinus ostium patency was maintained in 20 of 22 sinuses over an average follow-up period of 16.2 months. No complications were reported.The Draf IIB frontal sinusotomy is a relatively safe procedure, with multiple indications. Long-term sinus ostium patency was maintained in >90% of operated sinuses, which indicated that the Draf IIB procedure may present an acceptable alternative to more aggressive extended frontal sinus approaches in selected patients.

    View details for DOI 10.2500/ajra.2016.30.4268

    View details for Web of Science ID 000370446800013

    View details for PubMedID 26867534

  • Design and rationale of a prospective multi-institutional registry for patients with sinosodal malignancy The Laryngoscope Beswick, D. M., Holsinger, F. C., Kaplan, M. J., Fischbein, N. J., Hara, W. Y., Colevas, A. D., Le, Q. T., Berry, G. J., Hwang, P. H. 2016

    Abstract

    Assessment of patients with sinonasal malignancy is challenging due to the low disease incidence and diverse histopathology. The current literature is composed mainly of retrospective studies with heterogeneous cohorts, and the rarity of cases limits our understanding of disease characteristics and treatment outcomes. We describe the development of a prospective, multi-institutional registry that utilizes cloud-based computing to evaluate treatment outcomes in patients with sinonasal cancer.A web-based, secure database was built to prospectively capture longitudinal outcomes and quality-of-life (QoL) data in patients diagnosed with sinonasal malignancy. Demographics, tumor staging, and treatment outcomes data are being collected. The Sinonasal Outcome Test-22 and University of Washington Quality of Life Questionnaire are administered at presentation and at recurring intervals. To date, seven institutions are participating nationally.This prospective, multi-institutional registry will provide novel oncological and QoL outcomes on patients with sinonasal malignancy to inform management decisions and disease prognostication. The application of cloud-based computing facilitates secure multi-institutional collaboration and may serve as a model for future registry development for the study of rare diseases in otolaryngology.2C. Laryngoscope, 2016.

    View details for DOI 10.1002/lary.25996

  • Reply to: In reference to: Medical therapy vs surgery for recurrent acute rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Hwang, P. H., Costa, M. L., Psaltis, A. J., Nayak, J. V. 2015; 5 (12): 1186

    View details for PubMedID 26458500

  • Giant Prolactinoma Presenting with Neck Pain and Structural Compromise of the Occipital Condyles. Journal of neurological surgery reports Yecies, D., Ajlan, A., Ratliff, J., Ziskin, J., Hwang, P., Vogel, H., Katznelson, L., Harsh, G. 2015; 76 (2): e297-301

    Abstract

    Prolactinomas are the most common form of endocrinologically active pituitary adenoma; they account for ∼ 45% of pituitary adenomas encountered in clinical practice. Giant adenomas are those > 4 cm in diameter. Less than 0.5% of pituitary adenomas encountered in neurosurgical practice are giant prolactinomas. Patients with giant prolactinomas typically present with highly elevated prolactin levels, endocrinologic disturbances, and neurologic symptoms from mass-induced pressure. Described here is an unusual case of a giant prolactinoma presenting with neck pain and structural compromise of the occipital condyles. Transnasal biopsy of the nasopharyngeal portion of the mass obtained tissue consistent with an atypical prolactinoma with p53 reactivity and a high Ki-67 index of 5%. Despite the size and invasiveness of the tumor, the patient had resolution of his clinical symptoms, dramatic reduction of his hyperprolactinemia, and near-complete disappearance of his tumor following medical treatment.

    View details for DOI 10.1055/s-0035-1566124

    View details for PubMedID 26623246

  • C Perioperative Management of Antithrombotic Therapy in Common Otolaryngologic Surgical Procedures: State of the Art Review OTOLARYNGOLOGY-HEAD AND NECK SURGERY Hsueh, W. D., Hwang, P. H., Abuzeid, W. M. 2015; 153 (4): 493-503

    Abstract

    The perioperative management of patients undergoing otolaryngologic procedures is increasingly complicated by the use of newer antithrombotic agents. Furthermore, with advances in anesthesia and surgical technique, otolaryngologists are presented with the challenge of operating on patients with advanced comorbid diseases. The objective of this review is to provide evidence-based recommendations on perioperative antithrombotic management for common otolaryngologic procedures.PubMed/MEDLINE.Selected literature on patient-specific thromboembolic risk, rate of bleeding complications in otolaryngologic procedures, and the interruption of antithrombotic therapy is reviewed and interpreted by expert opinion.By stratifying patients into either low thromboembolic risk (≤ 5%) or high thromboembolic risk (> 5%) and interpreting this in the context of procedural bleed risk and potential clinical consequences in the event of a bleed, otolaryngologists can make evidence-based decisions to determine the appropriate perioperative management of antithrombotic therapy.When the perioperative management of antithrombotic therapy is being decided, 3 critical factors must be considered systematically: the patient's inherent thromboembolic risk, the risk and potential consequences of bleeding related to the procedure, and the timing of interruption of thromboembolic therapy.

    View details for DOI 10.1177/0194599815600409

    View details for Web of Science ID 000362445800006

    View details for PubMedID 26307580

  • Avoiding Complications in Endoscopic Sinus Surgery OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Humphreys, I. M., Hwang, P. H. 2015; 48 (5): 871-+

    Abstract

    Complications of endoscopic sinus surgery (ESS) can range from the mundane to the catastrophic, with nasal hemorrhage being the most common. Intraorbital and intracranial complications are much less common. Despite the rarity of complications, they are often avoidable. Certain identifiable risk factors can be appreciated during the preoperative, intraoperative, and postoperative evaluations of the sinus patient. With awareness of these risk factors the rhinologist can develop a strategic plan of risk factor mitigation. This article identifies areas of increased risk that are amenable to preventive strategies before complications become realized.

    View details for PubMedID 26117296

  • Secretion rates of human nasal submucosal glands from patients with chronic rhinosinusitis or cystic fibrosis. American journal of rhinology & allergy Jeong, J. H., Hwang, P. H., Cho, D., Joo, N. S., Wine, J. J. 2015; 29 (5): 334-338

    Abstract

    A majority of patients with cystic fibrosis (CF) have chronic rhinosinusitis (CRS) and/or nasal polyps, both of which may be secondary to reduced fluid secretion from nasal submucosal glands.To determine whether decreased fluid secretion from nasal submucosal glands also occurs in patients without CF and with CRS.Inferior turbinates of the nasal cavity were harvested from controls, subjects with CRS, and subjects with CF (n = 5-7 per group). The secretion rates of the nasal submucosal glands of the three groups in response to carbachol and forskolin were measured by using time lapse digital imaging of mucus bubbles from single glands as they formed on the mucosal surface under oil.Carbachol-stimulated secretion rates were the following: controls, 1670 ± 381 pl·min(-1)·gland(-1); CRS, 965 ± 440 pl·min(-1)·gland(-1); and CF, 933 ± 588 pl·min(-1)·gland(-1) (p = 0.23, Kruskal-Wallis test). Forskolin-stimulated secretion rates were the following: controls, 229 ± 14 pl·min(-1)·gland(-1); CRS, 154 ± 48 pl·min(-1)·gland(-1); and CF, 22 ± 15 pl·min(-1)·gland(-1) (p = 0.008, Kruskal-Wallis test). The ratio of the average secretion rate induced by forskolin to that induced by carbachol was 13.7% in the controls, and 15.9% in CRS and 2.3% in CF groups.The only significant difference in this small study was decreased forskolin-stimulated secretion in subjects with CF relative to the other subjects. However, there was a trend toward reduced carbachol-stimulated secretion rates in subjects with CRS and with and without CF relative to controls. Additional studies are needed to determine if nasal submucosal gland hyposecretion occurs in CRS either as a contributor to or as a consequence of CRS pathogenesis.

    View details for DOI 10.2500/ajra.2015.29.4213

    View details for PubMedID 26358343

  • Secretion rates of human nasal submucosal glands from patients with chronic rhinosinusitis or cystic fibrosis AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Jeong, J. H., Hwang, P. H., Cho, D., Joo, N. S., Wine, J. J. 2015; 29 (5): 334-338

    Abstract

    A majority of patients with cystic fibrosis (CF) have chronic rhinosinusitis (CRS) and/or nasal polyps, both of which may be secondary to reduced fluid secretion from nasal submucosal glands.To determine whether decreased fluid secretion from nasal submucosal glands also occurs in patients without CF and with CRS.Inferior turbinates of the nasal cavity were harvested from controls, subjects with CRS, and subjects with CF (n = 5-7 per group). The secretion rates of the nasal submucosal glands of the three groups in response to carbachol and forskolin were measured by using time lapse digital imaging of mucus bubbles from single glands as they formed on the mucosal surface under oil.Carbachol-stimulated secretion rates were the following: controls, 1670 ± 381 pl·min(-1)·gland(-1); CRS, 965 ± 440 pl·min(-1)·gland(-1); and CF, 933 ± 588 pl·min(-1)·gland(-1) (p = 0.23, Kruskal-Wallis test). Forskolin-stimulated secretion rates were the following: controls, 229 ± 14 pl·min(-1)·gland(-1); CRS, 154 ± 48 pl·min(-1)·gland(-1); and CF, 22 ± 15 pl·min(-1)·gland(-1) (p = 0.008, Kruskal-Wallis test). The ratio of the average secretion rate induced by forskolin to that induced by carbachol was 13.7% in the controls, and 15.9% in CRS and 2.3% in CF groups.The only significant difference in this small study was decreased forskolin-stimulated secretion in subjects with CF relative to the other subjects. However, there was a trend toward reduced carbachol-stimulated secretion rates in subjects with CRS and with and without CF relative to controls. Additional studies are needed to determine if nasal submucosal gland hyposecretion occurs in CRS either as a contributor to or as a consequence of CRS pathogenesis.

    View details for DOI 10.2500/ajra.2015.29.4213

    View details for Web of Science ID 000364337200011

    View details for PubMedID 26358343

  • Medical therapy vs surgery for recurrent acute rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (8): 667-673

    Abstract

    Treatment indications for recurrent acute rhinosinusitis (RARS) remain poorly defined. We studied outcomes of medical vs surgical treatment of RARS, anatomic variants associated with RARS, and factors predicting crossover from medical to surgical treatment.A total of 220 RARS patients treated between 2006 and 2014 were retrospectively divided into 3 cohorts: medical only (MED); surgical only (SURG); or medical crossing over into surgical (CROSS). Twenty-two item Sino-Nasal Outcome Test (SNOT-22) scores, modified Lund-Kennedy endoscopy scores, and prevalence of anatomic variants by computed tomography (CT) were compared. A total of 220 CT scans obtained for non-sinus indications served as controls. A logistic regression model was used for analysis.The mean baseline SNOT-22 scores for all cohorts were similar (MED = 48, SURG = 49, CROSS = 45, p < 0.0001). The SURG cohort showed greater reduction of SNOT-22 scores compared to the MED cohort at 3, 6, and 12 months follow-up (p < 0.0001). The crossover cohort converted to surgery after escalation of SNOT-22 score by a mean of 15 points (p < 0.03), and showed significant reduction postoperatively (p < 0.0001). Haller cell (odds ratio [OR] 3.9; p < 0.0001), concha bullosa (OR 3.7; p < 0.003), and accessory ostium (OR 2.2; p < 0.01) were more common in the entire RARS group vs controls; however, there were no inter-cohort differences in prevalence.RARS patients can benefit from both medical and surgical treatment strategies, but surgical treatment results in greater symptomatic improvement compared to medical treatment. Patients cross over from medical to surgical treatment when SNOT-22 scores escalate by a mean of 15 points. Haller cell, concha bullosa, and accessory ostium are associated with RARS but are equally common in medical, surgical, and crossover cohorts.

    View details for DOI 10.1002/alr.21533

    View details for Web of Science ID 000359053700002

    View details for PubMedID 25950995

  • Medical therapy vs surgery for recurrent acute rhinosinusitis. International forum of allergy & rhinology Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (8): 667-673

    Abstract

    Treatment indications for recurrent acute rhinosinusitis (RARS) remain poorly defined. We studied outcomes of medical vs surgical treatment of RARS, anatomic variants associated with RARS, and factors predicting crossover from medical to surgical treatment.A total of 220 RARS patients treated between 2006 and 2014 were retrospectively divided into 3 cohorts: medical only (MED); surgical only (SURG); or medical crossing over into surgical (CROSS). Twenty-two item Sino-Nasal Outcome Test (SNOT-22) scores, modified Lund-Kennedy endoscopy scores, and prevalence of anatomic variants by computed tomography (CT) were compared. A total of 220 CT scans obtained for non-sinus indications served as controls. A logistic regression model was used for analysis.The mean baseline SNOT-22 scores for all cohorts were similar (MED = 48, SURG = 49, CROSS = 45, p < 0.0001). The SURG cohort showed greater reduction of SNOT-22 scores compared to the MED cohort at 3, 6, and 12 months follow-up (p < 0.0001). The crossover cohort converted to surgery after escalation of SNOT-22 score by a mean of 15 points (p < 0.03), and showed significant reduction postoperatively (p < 0.0001). Haller cell (odds ratio [OR] 3.9; p < 0.0001), concha bullosa (OR 3.7; p < 0.003), and accessory ostium (OR 2.2; p < 0.01) were more common in the entire RARS group vs controls; however, there were no inter-cohort differences in prevalence.RARS patients can benefit from both medical and surgical treatment strategies, but surgical treatment results in greater symptomatic improvement compared to medical treatment. Patients cross over from medical to surgical treatment when SNOT-22 scores escalate by a mean of 15 points. Haller cell, concha bullosa, and accessory ostium are associated with RARS but are equally common in medical, surgical, and crossover cohorts.

    View details for DOI 10.1002/alr.21533

    View details for PubMedID 25950995

  • The impact of diabetes mellitus on outcomes of endoscopic sinus surgery: a nested case-control study. International forum of allergy & rhinology Hajjij, A., Mace, J. C., Soler, Z. M., Smith, T. L., Hwang, P. H. 2015; 5 (6): 533-540

    Abstract

    Given the immune impairment associated with diabetes mellitus (DM), its impact on chronic rhinosinusitis (CRS) is a potentially relevant concern; however, it has not been well-studied. A single retrospective study reported worse postoperative quality of life outcomes in DM patients with CRS. Our study evaluated the effect of comorbid DM on outcomes of endoscopic sinus surgery (ESS) using a prospective study design.Using a multicentered, prospective cohort of patients (n = 437) undergoing ESS for recalcitrant CRS, a nested case-control comparison was performed between 20 adult DM patients (cases) and 20 non-DM patients (controls), matched 1:1 for age and Lund-Mackay computed tomography (CT) scores. Outcome measures included 22-item Sinonasal Outcome Test (SNOT-22), Rhinosinusitis Disability Index (RSDI), Patient Health Questionnaire (PHQ-2), and Brief Smell Identification Test (BSIT).Mean follow-up was similar between cases (mean ± standard deviation: 12.6 ± 6.0 months) and controls (12.9 ± 5.9 months; p = 0.862). All preoperative scores were statistically equivalent between DM and non-DM cohorts. Both cohorts showed significant post-ESS improvement in SNOT-22 (p = 0.001) and RSDI scores (p < 0.001), and no significant change in PHQ-2 or BSIT scores. The magnitude of score changes was statistically equivalent between the 2 cohorts for all outcome measures with no differences in postoperative score changes between insulin-dependent DM patients and those managed by oral hypoglycemics or dietary restriction (p ≥ 0.444).DM patients with CRS experience similar degrees of symptomatic benefit from ESS compared to controls. Insulin dependence does not appear to adversely affect surgical outcome but a larger cohort would better assess the effect of DM type and control on surgical outcomes in CRS.

    View details for DOI 10.1002/alr.21495

    View details for PubMedID 25913815

  • The impact of diabetes mellitus on outcomes of endoscopic sinus surgery: a nested case-control study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Hajjij, A., Mace, J. C., Soler, Z. M., Smith, T. L., Hwang, P. H. 2015; 5 (6): 533-540

    Abstract

    Given the immune impairment associated with diabetes mellitus (DM), its impact on chronic rhinosinusitis (CRS) is a potentially relevant concern; however, it has not been well-studied. A single retrospective study reported worse postoperative quality of life outcomes in DM patients with CRS. Our study evaluated the effect of comorbid DM on outcomes of endoscopic sinus surgery (ESS) using a prospective study design.Using a multicentered, prospective cohort of patients (n = 437) undergoing ESS for recalcitrant CRS, a nested case-control comparison was performed between 20 adult DM patients (cases) and 20 non-DM patients (controls), matched 1:1 for age and Lund-Mackay computed tomography (CT) scores. Outcome measures included 22-item Sinonasal Outcome Test (SNOT-22), Rhinosinusitis Disability Index (RSDI), Patient Health Questionnaire (PHQ-2), and Brief Smell Identification Test (BSIT).Mean follow-up was similar between cases (mean ± standard deviation: 12.6 ± 6.0 months) and controls (12.9 ± 5.9 months; p = 0.862). All preoperative scores were statistically equivalent between DM and non-DM cohorts. Both cohorts showed significant post-ESS improvement in SNOT-22 (p = 0.001) and RSDI scores (p < 0.001), and no significant change in PHQ-2 or BSIT scores. The magnitude of score changes was statistically equivalent between the 2 cohorts for all outcome measures with no differences in postoperative score changes between insulin-dependent DM patients and those managed by oral hypoglycemics or dietary restriction (p ≥ 0.444).DM patients with CRS experience similar degrees of symptomatic benefit from ESS compared to controls. Insulin dependence does not appear to adversely affect surgical outcome but a larger cohort would better assess the effect of DM type and control on surgical outcomes in CRS.

    View details for DOI 10.1002/alr.21495

    View details for Web of Science ID 000355860600011

    View details for PubMedID 25913815

    View details for PubMedCentralID PMC4467792

  • Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis. International forum of allergy & rhinology Huang, Z., Hajjij, A., Li, G., Nayak, J. V., Zhou, B., Hwang, P. H. 2015; 5 (4): 303-309

    Abstract

    Neo-osteogenesis of the paranasal sinuses is a radiologic finding of unclear clinical significance. Although current evidence suggests that these bony changes represent an inflammatory response rather than an infectious osteitis, bacteria associated with the sinonasal mucosa may induce inflammatory mediators as a mechanism of neo-osteogenesis. The objectives of this study were (1) to determine whether there is an association between bacteria isolated on sinus culture and neo-osteogenesis, and (2) to identify other predictive factors for neo-osteogenesis.Ninety patients undergoing sinus surgery for medically refractory CRS were recruited. Radiologic evidence of neo-osteogenesis was assessed by the Global Osteitis Scoring Scale (GOSS) and mucosal disease severity was assessed by the Lund-Mackay score (LMS). Bacterial culture was obtained endoscopically at the preoperative office visit or during surgery. Multiple and logistic regression models were used to evaluate the association between the types of bacterial species isolated, number of previous surgeries, and severity of neo-osteogenesis.Thirty of the 90 (33.3%) patients had radiologic evidence of neo-osteogenesis. Pseudomonas aeruginosa was significantly associated with neo-osteogenesis (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.12 to 13.56), whereas Staphylococcus aureus was not. The number of previous surgeries, especially 2 or more previous surgeries, was associated with the extent of neo-osteogenesis (OR, 3.48; 95% CI, 1.14 to 10.51). The LMS was also significantly associated with the extent of neo-osteogenesis.The presence of P. aeruginosa in the sinuses is an independent predictor of neo-osteogenesis, whereas S. aureus is not. The number of previous surgeries and the LMS are also independently associated with the severity of neo-osteogenesis.

    View details for DOI 10.1002/alr.21485

    View details for PubMedID 25644047

  • The effects of topical agents on paranasal sinus mucosa healing: a rabbit study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Jain, R., Kim, R., Waldvogel-Thurlow, S., Hwang, P., Cornish, J., Douglas, R. 2015; 5 (4): 310-317

    Abstract

    Numerous topical agents have been used intraoperatively to enhance postoperative mucosal healing or reduce scar formation. However, the histological effects of many of these treatments have not been well described. This study investigates the impact of topical mometasone furoate, acitretin, lactoferrin, and Silastic sheet (Medtronic) on sinus mucosal healing in a rabbit model.Forty-eight New Zealand white rabbits underwent defined, localized stripping of a bilateral region of maxillary sinus mucosa. One of 6 treatments was placed in 1 maxillary sinus, and the treatment carrier was applied contralaterally (0.1% mometasone furoate, 0.25% and 0.5% acitretin, lactoferrin, Silastic, and no treatment; n = 8 each group). Rabbits were euthanized after 2 weeks and histological sections were examined with light microscopy.Treatment with acitretin 0.25% and 0.5% improved cilial recovery by 0.9 ± 0.5 (p = 0.003) and 0.5 ± 0.5 (p < 0.05), respectively. Acitretin 0.25% treatment also significantly reduced collagen in healing mucosa (5.1% ± 4.8%, p = 0.04). Conversely, rabbits treated with mometasone furoate 0.1% were more likely to have reduced cilial and goblet cell recovery. Intergroup comparisons demonstrated a significant improvement in cilial recovery scores with both acitretin doses compared with mometasone furoate (p < 0.05) and less collagen deposition in rabbits treated with placebo gel over Silastic (p < 0.05). Mucosa directly underlying a blood clot had a lower cilia score and impaired epithelial recovery (p < 0.001).Intraoperatively applied agents have the potential to significantly affect wound healing. Acitretin improved cilial recovery and reduced collagen deposition.

    View details for DOI 10.1002/alr.21470

    View details for Web of Science ID 000352580700008

    View details for PubMedID 25677963

  • Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Huang, Z., Hajjij, A., Li, G., Nayak, J. V., Zhou, B., Hwang, P. H. 2015; 5 (4): 303-309

    Abstract

    Neo-osteogenesis of the paranasal sinuses is a radiologic finding of unclear clinical significance. Although current evidence suggests that these bony changes represent an inflammatory response rather than an infectious osteitis, bacteria associated with the sinonasal mucosa may induce inflammatory mediators as a mechanism of neo-osteogenesis. The objectives of this study were (1) to determine whether there is an association between bacteria isolated on sinus culture and neo-osteogenesis, and (2) to identify other predictive factors for neo-osteogenesis.Ninety patients undergoing sinus surgery for medically refractory CRS were recruited. Radiologic evidence of neo-osteogenesis was assessed by the Global Osteitis Scoring Scale (GOSS) and mucosal disease severity was assessed by the Lund-Mackay score (LMS). Bacterial culture was obtained endoscopically at the preoperative office visit or during surgery. Multiple and logistic regression models were used to evaluate the association between the types of bacterial species isolated, number of previous surgeries, and severity of neo-osteogenesis.Thirty of the 90 (33.3%) patients had radiologic evidence of neo-osteogenesis. Pseudomonas aeruginosa was significantly associated with neo-osteogenesis (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.12 to 13.56), whereas Staphylococcus aureus was not. The number of previous surgeries, especially 2 or more previous surgeries, was associated with the extent of neo-osteogenesis (OR, 3.48; 95% CI, 1.14 to 10.51). The LMS was also significantly associated with the extent of neo-osteogenesis.The presence of P. aeruginosa in the sinuses is an independent predictor of neo-osteogenesis, whereas S. aureus is not. The number of previous surgeries and the LMS are also independently associated with the severity of neo-osteogenesis.

    View details for DOI 10.1002/alr.21485

    View details for Web of Science ID 000352580700007

    View details for PubMedID 25644047

  • Meningiomas of the tuberculum and diaphragma sellae. Journal of neurological surgery. Part B, Skull base Ajlan, A. M., Choudhri, O., Hwang, P., Harsh, G. 2015; 76 (1): 74-79

    Abstract

    Introduction Although tuberculum sellae (TS) and diaphragma sellae (DS) meningiomas have different anatomical origins, they are frequently discussed as a single entity. Here we review the radiologic and intraoperative findings of TS and DS meningiomas and propose a radiologic classification. Methods We retrospectively reviewed 10 consecutive TS and DS meningiomas. Data regarding clinical presentation, preoperative imaging, and intraoperative findings were analyzed. Three sellar dimensions were measured on magnetic resonance imaging (MRI): the tuberculum-sellar floor interval (TSFI), the planum-tuberculum interval (PTI), and the total height. Results Three distinct anatomical patterns were recognized: exclusively tubercular meningiomas (type A) were accompanied by elongation of the TSFI and, more significantly, of the PTI; combined TS and DS meningiomas (type B) were associated with relative elongation of both the PTI and TSFI; and the sole exclusively DS meningioma (type C) was associated with elongation of neither PTI nor TSFI. Conclusion Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI. Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach. Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach.

    View details for DOI 10.1055/s-0034-1390400

    View details for PubMedID 25685653

    View details for PubMedCentralID PMC4318732

  • Meningiomas of the tuberculum and diaphragma sellae. Journal of neurological surgery. Part B, Skull base Ajlan, A. M., Choudhri, O., Hwang, P., Harsh, G. 2015; 76 (1): 74-79

    Abstract

    Introduction Although tuberculum sellae (TS) and diaphragma sellae (DS) meningiomas have different anatomical origins, they are frequently discussed as a single entity. Here we review the radiologic and intraoperative findings of TS and DS meningiomas and propose a radiologic classification. Methods We retrospectively reviewed 10 consecutive TS and DS meningiomas. Data regarding clinical presentation, preoperative imaging, and intraoperative findings were analyzed. Three sellar dimensions were measured on magnetic resonance imaging (MRI): the tuberculum-sellar floor interval (TSFI), the planum-tuberculum interval (PTI), and the total height. Results Three distinct anatomical patterns were recognized: exclusively tubercular meningiomas (type A) were accompanied by elongation of the TSFI and, more significantly, of the PTI; combined TS and DS meningiomas (type B) were associated with relative elongation of both the PTI and TSFI; and the sole exclusively DS meningioma (type C) was associated with elongation of neither PTI nor TSFI. Conclusion Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI. Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach. Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach.

    View details for DOI 10.1055/s-0034-1390400

    View details for PubMedID 25685653

    View details for PubMedCentralID PMC4318732

  • Long-term outcomes of endoscopic maxillary mega-antrostomy for refractory chronic maxillary sinusitis. International forum of allergy & rhinology Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (1): 60-65

    Abstract

    Endoscopic maxillary mega-antrostomy (EMMA) is a revision surgical procedure for recalcitrant maxillary sinusitis in which medical therapy and endoscopic antrostomy have been unsuccessful. In 2008 our group published favorable outcomes of EMMA in 28 patients with relatively short follow-up and nonvalidated outcome measures. This study reports an update of long-term outcomes of this same cohort, as well as outcomes of an interval cohort of 94 patients using validated outcome measures.Retrospective review was performed for 122 patients (163 sides) who underwent EMMA between 2005 and 2013. For the original 2008 cohort, the original questionnaire from 2008 was readministered by telephone interview. For the interval cohort, preoperative and postoperative SNOT-22 symptom scores and modified Lund-Kennedy endoscopic scores were compared.The original 2008 cohort of 28 patients, now with a mean follow-up period of 6.9 years, demonstrated sustained improvement of symptoms. The outcomes were statistically comparable to the 2008 study, with 72.4% reporting complete or significant improvement, 27.6% reporting partial improvement, and 0% reporting worsening.

    View details for DOI 10.1002/alr.21407

    View details for PubMedID 25312656

  • Long-term outcomes of endoscopic maxillary mega-antrostomy for refractory chronic maxillary sinusitis. International forum of allergy & rhinology Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (1): 60-65

    View details for DOI 10.1002/alr.21407

    View details for PubMedID 25312656

  • Steroid-eluting sinus stents for improving symptoms in chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery COCHRANE DATABASE OF SYSTEMATIC REVIEWS Huang, Z., Hwang, P., Sun, Y., Zhou, B. 2015

    Abstract

    Functional endoscopic sinus surgery (FESS) has become a well-established approach for treating patients with chronic rhinosinusitis (CRS) refractory to medical management. However, the surgical outcome may be compromised by postoperative inflammation, polyposis and adhesions, which often require subsequent intervention. Bioabsorbable, steroid-eluting sinus stents are inserted into the nose, sinuses or both following surgery to prevent stenosis of the sinus openings during the postoperative healing period. The slow release of corticosteroid aims to decrease mucosal oedema and expedite wound healing. Whether a steroid-eluting stent offers any beneficial effects in terms of improving sinonasal symptoms has not been systematically reviewed.To assess the safety and efficacy of steroid-eluting sinus stent placement in CRS patients after FESS.The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 4); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 May 2015.We included all randomised controlled trials (RCTs) comparing steroid-eluting sinus stents with non-steroid-eluting sinus stents, nasal packing or no treatment in adult CRS patients undergoing FESS.We used the standard methodological procedures expected by The Cochrane Collaboration.We identified no RCTs that met our inclusion criteria. Among the 159 records retrieved using our search strategy, 21 trials had the potential to be included given that they had tested sinus stents, spacers and packing materials for patients with CRS undergoing FESS. However, we excluded these trials from the review because they met some but not all of the inclusion criteria.We are unable to provide evidence to establish whether steroid-eluting sinus stents have potential advantages and disadvantages for patients with CRS undergoing FESS. Future, high-quality RCTs are needed to assess whether or not steroid-eluting sinus stents confer any beneficial effects, over those of surgery alone, when compared to non-steroid sinus stents.

    View details for DOI 10.1002/14651858.CD010436.pub2

    View details for Web of Science ID 000357606400056

    View details for PubMedID 26068957

  • Complications associated with the pedicled nasoseptal flap for skull base reconstruction. Laryngoscope Soudry, E., Psaltis, A. J., Lee, K. H., Vaezafshar, R., Nayak, J. V., Hwang, P. H. 2015; 125 (1): 80-85

    Abstract

    To analyze complications associated with nasoseptal flap elevation and reconstruction in endoscopic skull base surgery.Case series.Retrospective chart review of all patients who underwent nasoseptal flap procedure in our institution between 2008 and 2013.A total of 121 patients were identified with a mean follow-up time of 10.4 months. Complications associated with this procedure occurred in 33 patients (27%). The majority of complications were related to the septal donor site and included septal perforation, cartilage necrosis, and prolonged crusting. Other complications included intraoperative injury to the flap pedicle (n = 4) or recurrent/persistent cerebrospinal fluid leak occurring in the early postoperative period (n = 7). Long-term quality-of-life data assessed via Sinonasal Outcome Test-22 questionnaires did not reveal notable differences when compared to preoperative scores.The complication rate associated with nasoseptal flap elevation and inset is higher than previously described. The majority of complications became manifest beyond the immediate postoperative period and were associated with the septal donor site, including septal perforation, prolonged crusting, and cartilage necrosis. We hypothesize that donor site morbidity may be related to compromise of the contralateral septal vascular supply during the procedure. The range and frequency of complications of nasal septal flap surgery should be considered in counseling patients who may receive a nasoseptal flap for skull base reconstruction.4. Laryngoscope, 125:80-85, 2015.

    View details for DOI 10.1002/lary.24863

    View details for PubMedID 25111727

  • Air pollutants cause release of hydrogen peroxide and interleukin-8 in a human primary nasal tissue culture model. International forum of allergy & rhinology Cho, D., Le, W., Bravo, D. T., Hwang, P. H., Illek, B., Fischer, H., Nayak, J. V. 2014; 4 (12): 966-971

    Abstract

    A component of primary innate defense of the nasal mucosa against inhaled pathogens includes continuous, low-level release of hydrogen peroxide (H2 O2 ) into luminal secretions. Epidemiologically, an association exists between poor air quality and increased prevalence of sinonasal disease. To understand the effects of particulate matter (PM) in nasal mucosa, we studied the release of H2 O2 and interleukin 8 (IL-8) after PM exposure.Human nasal specimens were collected from surgery and cultured in serum-free growth medium. Cell integrity and recovery during culture was monitored by lactate dehydrogenase (LDH) release into the medium. Cultures were exposed to PM for 24 hours in the presence/absence of diphenyleneiodonium sulfate (DPI; a nicotinamide adenine dinucleotide phosphate [NADPH] oxidase inhibitor). Luminex cytokine and Amplex-Red H2 O2 assays were performed.LDH levels dropped rapidly within 2 days, indicative of stabilization and cell recovery after harvest. All cultures released H2 O2 into the medium. Exposure to PM (20 μg/cm(2) ) increased H2 O2 levels significantly (94.6 ± 7.7 nM) compared to untreated controls (55.8 ± 4.0 nM; p = 0.001). PM-induced H2 O2 production was partially inhibited by DPI (80.1 ± 3.8nM), indicating that cellular NADPH oxidase may be a primary source of H2 O2 production. Exposure to PM increased IL-8 levels in a dose-dependent fashion (control = 2301 ± 412 MFI; 20 μg/cm(2) = 5002 ± 1327 MFI; 40 μg/cm(2) = 8219 ± 1090 MFI; p = 0.022).PM increases the quantity of H2 O2 released by nasal epithelial cells, indicating that PM can contribute to oxidative stress in part by activating a normal cellular defense mechanism. Exposure to PM resulted in elevated IL-8 levels and mucin production in explants. Efforts to reduce airborne PM may lead to reduced H2 O2 and mucin production in sinonasal epithelium.

    View details for DOI 10.1002/alr.21413

    View details for PubMedID 25400124

  • The effect of radiofrequency turbinoplasty vs two other methods in the management of polypoid changes of the middle turbinate: a randomized trial INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Saedi, B., Amali, A., Alizadeh, N., Hwang, P., Meisami, A. 2014; 4 (12): 1030–34

    Abstract

    The aim of this study was to evaluate the effectiveness of middle turbinate radiofrequency (RF) turbinoplasty for the management of the polypoid middle turbinate compared to middle turbinate resection and middle turbinate medialization.The study was performed on 90 patients at a tertiary referral hospital with nasal polyposis resistant to maximal medical treatment. At the time of functional endoscopic sinus surgery (FESS), patients were randomized into 3 groups with respect to the management of the middle turbinate: middle turbinate turbinoplasty by RF; partial resection of the middle turbinate; and medialization of the middle turbinate by scarification to the septum. We evaluated the patients' symptoms according to the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and 1 year after surgery. Additionally, polyp recurrence and complications were compared among the 3 groups.One year after surgery, there was no significant difference in SNOT-22 scores between the groups. However, the RF group had a significantly lower polyp recurrence rate when compared to other groups (p < 0.05).RF middle turbinate turbinoplasty could be considered an alternative to other common approaches, but it needs further long-term studies before widespread usage.

    View details for DOI 10.1002/alr.21399

    View details for Web of Science ID 000346022600014

    View details for PubMedID 25187345

  • Air pollutants cause release of hydrogen peroxide and interleukin-8 in a human primary nasal tissue culture model INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Cho, D., Le, W., Bravo, D. T., Hwang, P. H., Illek, B., Fischer, H., Nayak, J. V. 2014; 4 (12): 966-971

    Abstract

    A component of primary innate defense of the nasal mucosa against inhaled pathogens includes continuous, low-level release of hydrogen peroxide (H2 O2 ) into luminal secretions. Epidemiologically, an association exists between poor air quality and increased prevalence of sinonasal disease. To understand the effects of particulate matter (PM) in nasal mucosa, we studied the release of H2 O2 and interleukin 8 (IL-8) after PM exposure.Human nasal specimens were collected from surgery and cultured in serum-free growth medium. Cell integrity and recovery during culture was monitored by lactate dehydrogenase (LDH) release into the medium. Cultures were exposed to PM for 24 hours in the presence/absence of diphenyleneiodonium sulfate (DPI; a nicotinamide adenine dinucleotide phosphate [NADPH] oxidase inhibitor). Luminex cytokine and Amplex-Red H2 O2 assays were performed.LDH levels dropped rapidly within 2 days, indicative of stabilization and cell recovery after harvest. All cultures released H2 O2 into the medium. Exposure to PM (20 μg/cm(2) ) increased H2 O2 levels significantly (94.6 ± 7.7 nM) compared to untreated controls (55.8 ± 4.0 nM; p = 0.001). PM-induced H2 O2 production was partially inhibited by DPI (80.1 ± 3.8nM), indicating that cellular NADPH oxidase may be a primary source of H2 O2 production. Exposure to PM increased IL-8 levels in a dose-dependent fashion (control = 2301 ± 412 MFI; 20 μg/cm(2) = 5002 ± 1327 MFI; 40 μg/cm(2) = 8219 ± 1090 MFI; p = 0.022).PM increases the quantity of H2 O2 released by nasal epithelial cells, indicating that PM can contribute to oxidative stress in part by activating a normal cellular defense mechanism. Exposure to PM resulted in elevated IL-8 levels and mucin production in explants. Efforts to reduce airborne PM may lead to reduced H2 O2 and mucin production in sinonasal epithelium.

    View details for DOI 10.1002/alr.21413

    View details for Web of Science ID 000346022600004

    View details for PubMedID 25400124

  • SNOT-22 quality of life domains differentially predict treatment modality selection in chronic rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY DeConde, A. S., Mace, J. C., Bodner, T., Hwang, P. H., Rudmik, L., Soler, Z. M., Smith, T. L. 2014; 4 (12): 972-979

    Abstract

    Prior study demonstrated that baseline 22-item Sino-Nasal Outcome Test (SNOT-22) aggregate scores accurately predict selection of surgical intervention in patients with chronic rhinosinusitis (CRS). Factor analysis of the SNOT-22 survey has identified five distinct domains that are differentially impacted by endoscopic sinus surgery (ESS). This study sought to quantify SNOT-22 domains in patient cohorts electing both surgical or medical management and postinterventional change in these domains.CRS patients were prospectively enrolled into a multi-institutional, observational cohort study. Subjects elected continued medical management or ESS. SNOT-22 domain scores at baseline were compared between treatment cohorts. Postintervention domain score changes were evaluated in subjects with at least six-month follow-up.A total of 363 subjects were enrolled with 72 (19.8%) electing continued medical management, whereas 291 (80.2%) elected ESS. Baseline SNOT-22 domain scores were comparable between treatment cohorts in sinus-specific domains (rhinologic, extranasal rhinologic, and ear/facial symptoms; p > 0.050); however, the surgical cohort reported significantly higher psychological (mean ± standard deviation [SD]: 16.0 ± 8.4 vs 12.0 ± 7.1; p < 0.001) and sleep dysfunction (13.7 ± 6.8 vs 10.5 ± 6.2; p < 0.001) than the medical cohort. Effect sizes for ESS varied across domains with rhinologic and extranasal rhinologic symptoms experiencing the greatest gains (1.067 and 0.997, respectively), whereas psychological and sleep dysfunction experiencing the smallest improvements (0.805 and 0.818, respectively). Patients experienced greater mean improvements after ESS in all domains compared to medical management (p < 0.001).Subjects electing ESS report higher sleep and psychological dysfunction compared to medical management but have comparable sinus-specific symptoms. Subjects undergoing ESS experience greater gains compared to medical management across all domains; however, these gains are smallest in the psychological and sleep domains.

    View details for DOI 10.1002/alr.21408

    View details for Web of Science ID 000346022600005

    View details for PubMedID 25323055

    View details for PubMedCentralID PMC4260999

  • SNOT-22 quality of life domains differentially predict treatment modality selection in chronic rhinosinusitis. International forum of allergy & rhinology DeConde, A. S., Mace, J. C., Bodner, T., Hwang, P. H., Rudmik, L., Soler, Z. M., Smith, T. L. 2014; 4 (12): 972-979

    Abstract

    Prior study demonstrated that baseline 22-item Sino-Nasal Outcome Test (SNOT-22) aggregate scores accurately predict selection of surgical intervention in patients with chronic rhinosinusitis (CRS). Factor analysis of the SNOT-22 survey has identified five distinct domains that are differentially impacted by endoscopic sinus surgery (ESS). This study sought to quantify SNOT-22 domains in patient cohorts electing both surgical or medical management and postinterventional change in these domains.CRS patients were prospectively enrolled into a multi-institutional, observational cohort study. Subjects elected continued medical management or ESS. SNOT-22 domain scores at baseline were compared between treatment cohorts. Postintervention domain score changes were evaluated in subjects with at least six-month follow-up.A total of 363 subjects were enrolled with 72 (19.8%) electing continued medical management, whereas 291 (80.2%) elected ESS. Baseline SNOT-22 domain scores were comparable between treatment cohorts in sinus-specific domains (rhinologic, extranasal rhinologic, and ear/facial symptoms; p > 0.050); however, the surgical cohort reported significantly higher psychological (mean ± standard deviation [SD]: 16.0 ± 8.4 vs 12.0 ± 7.1; p < 0.001) and sleep dysfunction (13.7 ± 6.8 vs 10.5 ± 6.2; p < 0.001) than the medical cohort. Effect sizes for ESS varied across domains with rhinologic and extranasal rhinologic symptoms experiencing the greatest gains (1.067 and 0.997, respectively), whereas psychological and sleep dysfunction experiencing the smallest improvements (0.805 and 0.818, respectively). Patients experienced greater mean improvements after ESS in all domains compared to medical management (p < 0.001).Subjects electing ESS report higher sleep and psychological dysfunction compared to medical management but have comparable sinus-specific symptoms. Subjects undergoing ESS experience greater gains compared to medical management across all domains; however, these gains are smallest in the psychological and sleep domains.

    View details for DOI 10.1002/alr.21408

    View details for PubMedID 25323055

  • Endoscopic resection of a giant intradural retroclival ecchordosis physaliphora: surgical technique and literature review. World neurosurgery Choudhri, O., Feroze, A., Hwang, P., Vogel, H., Ajlan, A., Harsh, G. 2014; 82 (5): 912 e21-6

    Abstract

    To report the first complete resection of a giant ecchordosis physaliphora using an endoscopic transclival approach and to provide a current review of the literature.This rare benign lesion, originating from embryonic notochordal remnants, was located in the prepontine cistern of a 63-year-old man presenting with progressive tremor and imbalance. Preoperative imaging demonstrated a 2.1-cm intradural lesion abutting the pons and basilar artery and extending through the dura mater.A gross total resection was successfully achieved endoscopically without neurovascular compromise or additional complications. Postoperative histopathologic examination was consistent with a diagnosis of giant ecchordosis physaliphora.An endoscopic endonasal transclival approach provided a direct, minimally invasive route for safe and complete resection of this rare prepontine tumor, as it has for similarly located skull base chordomas. Our experience highlights the utility of endoscopy in visualization of both pathologic entities and nearby critical neurovascular structures in the management of ecchordosis physaliphora and other cranial base neoplasms.

    View details for DOI 10.1016/j.wneu.2014.06.019

    View details for PubMedID 24937599

  • Endoscopic resection of a giant intradural retroclival ecchordosis physaliphora: surgical technique and literature review. World neurosurgery Choudhri, O., Feroze, A., Hwang, P., Vogel, H., Ajlan, A., Harsh, G. 2014; 82 (5): 912 e21-6

    View details for DOI 10.1016/j.wneu.2014.06.019

    View details for PubMedID 24937599

  • Management of frontal sinus fractures: treatment modality changes at a level I trauma center. journal of craniofacial surgery Fox, P. M., Garza, R., Dusch, M., Hwang, P. H., Girod, S. 2014; 25 (6): 2038-2042

    Abstract

    The optimal management of frontal sinus fractures remains controversial, and previously accepted indications for surgical intervention are being challenged. The goals of this study were to determine how frontal sinus fracture management has changed at a single institution across multiple disciplines and to evaluate the long-term outcomes of operative and nonoperative treatment modalities.Patients treated for a frontal sinus fracture at Stanford Hospital and Clinics between June 1998 and June 2009 were included in the study. Inpatient records, clinic notes, operative reports, and radiographic studies were reviewed. The patients were invited for a follow-up clinic visit, physical examination, and focused sinus computed tomography. For a period of 11 years, 124 patients were treated for a frontal sinus fracture by physicians from 3 surgical subspecialties: otolaryngology, plastic surgery, and neurosurgery. A low short-term complication rate was observed (5.6%), and there was a trend toward nonsurgical management within the study population. Ten patients returned for a long-term follow-up. Of these, the 2 patients who underwent cranialization experienced as many or more long-term complications compared with the patients treated by other modalities. These complications included abnormal frontal bone contour with bony discontinuity and altered sensation in the distribution of the trigeminal nerve.The demonstrated trend toward nonsurgical management of frontal sinus fractures seems to be safe. In the limited group of patients who returned for follow-up, more long-term complications were observed in the patients who underwent cranialization. However, a larger long-term follow-up cohort will be necessary to elucidate the relationship between treatment modality and long-term outcomes and complications.

    View details for DOI 10.1097/SCS.0000000000001105

    View details for PubMedID 25377963

  • Management of Frontal Sinus Fractures: Treatment Modality Changes at a Level I Trauma Center JOURNAL OF CRANIOFACIAL SURGERY Fox, P. M., Garza, R., Dusch, M., Hwang, P. H., Girod, S. 2014; 25 (6): 2038-2042

    Abstract

    The optimal management of frontal sinus fractures remains controversial, and previously accepted indications for surgical intervention are being challenged. The goals of this study were to determine how frontal sinus fracture management has changed at a single institution across multiple disciplines and to evaluate the long-term outcomes of operative and nonoperative treatment modalities.Patients treated for a frontal sinus fracture at Stanford Hospital and Clinics between June 1998 and June 2009 were included in the study. Inpatient records, clinic notes, operative reports, and radiographic studies were reviewed. The patients were invited for a follow-up clinic visit, physical examination, and focused sinus computed tomography. For a period of 11 years, 124 patients were treated for a frontal sinus fracture by physicians from 3 surgical subspecialties: otolaryngology, plastic surgery, and neurosurgery. A low short-term complication rate was observed (5.6%), and there was a trend toward nonsurgical management within the study population. Ten patients returned for a long-term follow-up. Of these, the 2 patients who underwent cranialization experienced as many or more long-term complications compared with the patients treated by other modalities. These complications included abnormal frontal bone contour with bony discontinuity and altered sensation in the distribution of the trigeminal nerve.The demonstrated trend toward nonsurgical management of frontal sinus fractures seems to be safe. In the limited group of patients who returned for follow-up, more long-term complications were observed in the patients who underwent cranialization. However, a larger long-term follow-up cohort will be necessary to elucidate the relationship between treatment modality and long-term outcomes and complications.

    View details for DOI 10.1097/SCS.0000000000001105

    View details for Web of Science ID 000345012000054

  • Spontaneous Sphenoid Wing Meningoencephaloceles with Lateral Sphenoid Sinus Extension: The Endoscopic Transpterygoid Approach JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Ajlan, A., Achrol, A., Soudry, E., Hwang, P. H., Harsh, G. 2014; 75 (5): 314-323

    Abstract

    Spontaneous meningoencephalocele (SME) of the sphenoid wing is a rare cause of cerebrospinal fluid (CSF) leakage. Surgical closure of the fistula is usually required. The approach taken depends on the location of the defect and the extension of the meningoencephalocele. The endoscopic transpterygoid approach may be useful. We prospectively analyzed the three cases of SME of the sphenoid wing with lateral sphenoid sinus extension treated endoscopically at Stanford over the last 3 years with regard to imaging findings, operative technique, and operative morbidity. In our three cases, the extent of pterygopalatine fossa (PPF) exposure undertaken, complete in one and partial in two, depended on the defect site. Follow-up ranged from 17 to 25 months. The fistula was completely closed in all three cases. Extant literature reports a 97% rate of successful closure (N = 65 of 67, with a mean follow-up of 25 months) and no major complications. Endoscopic transpterygoid repair is a useful, safe alternative to traditional approaches for repair of SME of the sphenoid wing. Its feasibility depends on the site of the defect, which can be identified by preoperative imaging. Larger PPF exposure and postoperative lumbar drainage of CSF can be useful and have a low risk of morbidity.

    View details for DOI 10.1055/s-0034-1372465

    View details for Web of Science ID 000342840300004

    View details for PubMedCentralID PMC4176543

  • Long-term sinonasal outcomes of aspirin desensitization in aspirin exacerbated respiratory disease. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Cho, K., Soudry, E., Psaltis, A. J., Nadeau, K. C., McGhee, S. A., Nayak, J. V., Hwang, P. H. 2014; 151 (4): 575-581

    Abstract

    This study aimed to assess sinonasal outcomes in patients with aspirin exacerbated respiratory disease (AERD) undergoing aspirin desensitization following endoscopic sinus surgery (ESS).Case series with chart review.University hospital.A retrospective review of sinonasal outcomes was conducted for 30 AERD patients undergoing aspirin desensitization and maintenance therapy following ESS. Sinonasal outcomes were prospectively assessed by the Sinonasal Outcomes Test-22 (SNOT-22) and endoscopic polyp grading system. Data were collected preoperatively, 1 and 4 weeks postsurgery (before desensitization), and 1, 6, 12, 18, 24, and 30 months after aspirin desensitization.Twenty-eight of 30 patients (93.3%) successfully completed aspirin desensitization, whereas 2 of 30 (6.7%) were unable to complete desensitization due to respiratory intolerance. Of the 21 patients who successfully completed a minimum of 24 weeks of follow-up, 20 (95.2%) patients demonstrated sustained endoscopic and symptomatic improvement for a median follow-up period of 33 months. After surgical treatment but before desensitization, patients experienced significant reductions in SNOT-22 and polyp grade scores. In the first 6 months after aspirin desensitization, patients experienced further significant reductions in SNOT-22 scores, whereas polyp grade remained stable. The improvements in symptom endoscopic scores were preserved throughout the follow-up period after desensitization. No patients required additional sinus surgery. One patient had to discontinue aspirin therapy due to gastrointestinal side effects. No other adverse reactions to aspirin were noted.Aspirin desensitization following ESS appears to be a well-tolerated and effective adjunctive therapy for long-term control of nasal polyposis in patients with AERD.

    View details for DOI 10.1177/0194599814545750

    View details for PubMedID 25118195

  • Modification of the Lund-Kennedy endoscopic scoring system improves its reliability and correlation with patient-reported outcome measures. Laryngoscope Psaltis, A. J., Li, G., Vaezeafshar, R., Cho, K., Hwang, P. H. 2014; 124 (10): 2216-2223

    Abstract

    To compare three existing endoscopic scoring systems and a newly proposed modified scoring system for the assessment of patients with chronic rhinosinusitis (CRS).Blinded, prospective cohort study.CRS patients completed two patient-reported outcome measures (PROMs)-the visual analogue scale (VAS) symptom score and the Sino-Nasal Outcome Test-22 (SNOT-22)-and then underwent a standardized, recorded sinonasal endoscopy. Videos were scored by three blinded rhinologists using three scoring systems: the Lund-Kennedy (LK) endoscopic score; the Discharge, Inflammation, Polyp (DIP) score; and the Perioperative Sinonasal Endoscopic score. The videos were further scored using a modified Lund-Kennedy (MLK) endoscopic scoring system, which retains the LK subscores of polyps, edema, and discharge but eliminates the scoring of scarring and crusting. The systems were compared for test-retest and inter-rater reliability as well as for their correlation with PROMs.One hundred two CRS patients were enrolled. The MLK system showed the highest inter-rater and test-retest reliability of all scoring systems. All systems except for the DIP correlated with total VAS scores. The MLK was the only system that correlated with the symptom subscore of the SNOT-22 in both unoperated and postoperative patients.Modification of the LK system by excluding the subscores of scarring and crusting improves its reliability and its correlation with PROMs. In addition, the MLK system retains the familiarity of the widely used LK system and is applicable to any patient irrespective of surgical status. The MLK system may be a more suitable and reliable endoscopic scoring system for clinical practice and outcomes research.

    View details for DOI 10.1002/lary.24654

    View details for PubMedID 24615873

  • Spontaneous sphenoid wing meningoencephaloceles with lateral sphenoid sinus extension: the endoscopic transpterygoid approach. Journal of neurological surgery. Part B, Skull base Ajlan, A., Achrol, A., Soudry, E., Hwang, P. H., Harsh, G. 2014; 75 (5): 314-323

    Abstract

    Spontaneous meningoencephalocele (SME) of the sphenoid wing is a rare cause of cerebrospinal fluid (CSF) leakage. Surgical closure of the fistula is usually required. The approach taken depends on the location of the defect and the extension of the meningoencephalocele. The endoscopic transpterygoid approach may be useful. We prospectively analyzed the three cases of SME of the sphenoid wing with lateral sphenoid sinus extension treated endoscopically at Stanford over the last 3 years with regard to imaging findings, operative technique, and operative morbidity. In our three cases, the extent of pterygopalatine fossa (PPF) exposure undertaken, complete in one and partial in two, depended on the defect site. Follow-up ranged from 17 to 25 months. The fistula was completely closed in all three cases. Extant literature reports a 97% rate of successful closure (N = 65 of 67, with a mean follow-up of 25 months) and no major complications. Endoscopic transpterygoid repair is a useful, safe alternative to traditional approaches for repair of SME of the sphenoid wing. Its feasibility depends on the site of the defect, which can be identified by preoperative imaging. Larger PPF exposure and postoperative lumbar drainage of CSF can be useful and have a low risk of morbidity.

    View details for DOI 10.1055/s-0034-1372465

    View details for PubMedID 25302142

  • Long-term Sinonasal Outcomes of Aspirin Desensitization in Aspirin Exacerbated Respiratory Disease OTOLARYNGOLOGY-HEAD AND NECK SURGERY Cho, K., Soudry, E., Psaltis, A. J., Nadeau, K. C., McGhee, S. A., Nayak, J. V., Hwang, P. H. 2014; 151 (4): 575-581

    Abstract

    This study aimed to assess sinonasal outcomes in patients with aspirin exacerbated respiratory disease (AERD) undergoing aspirin desensitization following endoscopic sinus surgery (ESS).Case series with chart review.University hospital.A retrospective review of sinonasal outcomes was conducted for 30 AERD patients undergoing aspirin desensitization and maintenance therapy following ESS. Sinonasal outcomes were prospectively assessed by the Sinonasal Outcomes Test-22 (SNOT-22) and endoscopic polyp grading system. Data were collected preoperatively, 1 and 4 weeks postsurgery (before desensitization), and 1, 6, 12, 18, 24, and 30 months after aspirin desensitization.Twenty-eight of 30 patients (93.3%) successfully completed aspirin desensitization, whereas 2 of 30 (6.7%) were unable to complete desensitization due to respiratory intolerance. Of the 21 patients who successfully completed a minimum of 24 weeks of follow-up, 20 (95.2%) patients demonstrated sustained endoscopic and symptomatic improvement for a median follow-up period of 33 months. After surgical treatment but before desensitization, patients experienced significant reductions in SNOT-22 and polyp grade scores. In the first 6 months after aspirin desensitization, patients experienced further significant reductions in SNOT-22 scores, whereas polyp grade remained stable. The improvements in symptom endoscopic scores were preserved throughout the follow-up period after desensitization. No patients required additional sinus surgery. One patient had to discontinue aspirin therapy due to gastrointestinal side effects. No other adverse reactions to aspirin were noted.Aspirin desensitization following ESS appears to be a well-tolerated and effective adjunctive therapy for long-term control of nasal polyposis in patients with AERD.

    View details for DOI 10.1177/0194599814545750

    View details for Web of Science ID 000342982900008

  • Modification of the Lund-Kennedy Endoscopic Scoring System Improves Its Reliability and Correlation With Patient-Reported Outcome Measures LARYNGOSCOPE Psaltis, A. J., Li, G., Vaezeafshar, R., Cho, K., Hwang, P. H. 2014; 124 (10): 2216-2223

    Abstract

    To compare three existing endoscopic scoring systems and a newly proposed modified scoring system for the assessment of patients with chronic rhinosinusitis (CRS).Blinded, prospective cohort study.CRS patients completed two patient-reported outcome measures (PROMs)-the visual analogue scale (VAS) symptom score and the Sino-Nasal Outcome Test-22 (SNOT-22)-and then underwent a standardized, recorded sinonasal endoscopy. Videos were scored by three blinded rhinologists using three scoring systems: the Lund-Kennedy (LK) endoscopic score; the Discharge, Inflammation, Polyp (DIP) score; and the Perioperative Sinonasal Endoscopic score. The videos were further scored using a modified Lund-Kennedy (MLK) endoscopic scoring system, which retains the LK subscores of polyps, edema, and discharge but eliminates the scoring of scarring and crusting. The systems were compared for test-retest and inter-rater reliability as well as for their correlation with PROMs.One hundred two CRS patients were enrolled. The MLK system showed the highest inter-rater and test-retest reliability of all scoring systems. All systems except for the DIP correlated with total VAS scores. The MLK was the only system that correlated with the symptom subscore of the SNOT-22 in both unoperated and postoperative patients.Modification of the LK system by excluding the subscores of scarring and crusting improves its reliability and its correlation with PROMs. In addition, the MLK system retains the familiarity of the widely used LK system and is applicable to any patient irrespective of surgical status. The MLK system may be a more suitable and reliable endoscopic scoring system for clinical practice and outcomes research.

    View details for DOI 10.1002/lary.24654

    View details for Web of Science ID 000342749100007

  • Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Gan, E. C., Thamboo, A., Rudmik, L., Hwang, P. H., Ferguson, B. J., Javer, A. R. 2014; 4 (9): 702-715

    Abstract

    Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence-based approach for the medical management of AFRS.A systemic review of the literature on the medical management of AFRS was performed using Medline, EMBASE, and Cochrane Review Databases up to March 15, 2013. The inclusion criteria were as follows: patients >18 years old; AFRS as defined by Bent and Kuhn; post-sinus surgery; studies with a clearly defined end point to evaluate the effectiveness of medical therapy in postoperative AFRS patients.This review identified and assessed 6 medical modalities for AFRS in the literature: oral steroids; topical steroids; oral antifungals; topical antifungals; immunotherapy; and leukotriene modulators.Based on available evidence in the literature, postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS. Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS. No recommendations can be provided for topical antifungals and leukotriene modulators due to insufficient clinical research reported in the literature.

    View details for DOI 10.1002/alr.21352

    View details for Web of Science ID 000341767900003

    View details for PubMedID 25044729

  • Frontal ostium neo-osteogenesis and patency after Draf III procedure: a computer-assisted study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Ye, T., Hwang, P. H., Huang, Z., Huang, Q., Xian, J., Li, C., Zhou, B. 2014; 4 (9): 739-744

    Abstract

    Stenosis of the frontal neo-ostium after Draf III procedure has been associated with inflammatory risk factors. However, the degree to which neo-osteogenesis contributes to postsurgical stenosis of the frontal neo-ostium is unclear.Twenty-five patients with chronic frontal sinusitis who underwent Draf III procedure and had been followed for at least 12 months were included. Paranasal sinus computed tomography (CT) scans were performed 7 days and 1 year postoperatively. The frontal neo-ostium cross-sectional area and the amount of frontal neo-osteogenesis were measured by a standardized protocol using triplanar radiologic viewing software. Association between the severity of frontal neo-osteogenesis and the patency of the neo-ostium was analyzed, as was the correlation between the extent of neo-osteogenesis and the preoperative Global Osteitis Scoring Scale (GOSS), Lund-Mackay score (LMS), Lund-Kennedy score (LKS), serum eosinophil count, and history of previous surgery.At 1 year postoperatively, significant inverse correlation was found between the size of the frontal neo-ostium and the extent of neo-osteogenesis. According to a multiple linear regression model, the severity of neo-osteogenesis was positively correlated with preoperative GOSS and negatively correlated with asthma (p < 0.05). Additionally, there was no association between extent of neo-osteogenesis and the preoperative LMS, LKS, serum eosinophil count, and history of previous surgery.Neo-osteogenesis has a significant impact on the patency of the frontal neo-ostium but appears unrelated to inflammatory factors. Patients with a higher risk for developing neo-osteogenesis can be identified preoperatively based on GOSS; these patients may benefit from closer monitoring during the follow-up period.

    View details for DOI 10.1002/alr.21357

    View details for Web of Science ID 000341767900007

    View details for PubMedID 25079177

  • Productivity costs in patients with refractory chronic rhinosinusitis. Laryngoscope Rudmik, L., Smith, T. L., Schlosser, R. J., Hwang, P. H., Mace, J. C., Soler, Z. M. 2014; 124 (9): 2007-2012

    Abstract

    Disease-specific reductions in patient productivity can lead to substantial economic losses to society. The purpose of this study was to: 1) define the annual productivity cost for a patient with refractory chronic rhinosinusitis (CRS) and 2) evaluate the relationship between degree of productivity cost and CRS-specific characteristics.Prospective, multi-institutional, observational cohort study.The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time was quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 U.S. National Census and the 2013 U.S. Department of Labor statistics.A total of 55 patients with refractory CRS were enrolled. The mean work days lost related to absenteeism and presenteeism were 24.6 and 38.8 days per year, respectively. A total of 21.2 household days were lost per year related to daily sinus care requirements. The overall annual productivity cost was $10,077.07 per patient with refractory CRS. Productivity costs increased with worsening disease-specific QoL (r = 0.440; p = 0.001).Results from this study have demonstrated that the annual productivity cost associated with refractory CRS is $10,077.07 per patient. This substantial cost to society provides a strong incentive to optimize current treatment protocols and continue evaluating novel clinical interventions to reduce this cost.N/A. Laryngoscope, 124:2007-2012, 2014.

    View details for DOI 10.1002/lary.24630

    View details for PubMedID 24619604

    View details for PubMedCentralID PMC4125547

  • Update on evidence-based reviews with recommendations in adult chronic rhinosinusitis. International forum of allergy & rhinology Orlandi, R. R., Smith, T. L., Marple, B. F., Harvey, R. J., Hwang, P. H., Kern, R. C., Kingdom, T. T., Luong, A., Rudmik, L., Senior, B. A., Toskala, E., Kennedy, D. W. 2014; 4: S1-S15

    Abstract

    Chronic rhinosinusitis (CRS) has a significant impact not only on individuals who are afflicted but also on society as a whole. An increasing emphasis is being placed on incorporating the best available evidence into the care of patients, in association with an individual clinician's expertise and the patient's values. Recent evidence-based reviews with recommendations (EBRRs) have distilled our knowledge of CRS treatment options and have also pointed out continued gaps in this knowledge. This review synthesizes the findings of 8 EBRRs regarding CRS published in the International Forum of Allergy and Rhinology between 2011 and 2014. The recommendations in this review are based on the best available evidence and are meant to be incorporated into each patient's individual care, along with the practitioner's expertise and the individual patient's values and expectations. It is hoped that the EBRRs, and the process that spawned them, can provide the foundation for future guidelines in the diagnosis and management of CRS.

    View details for DOI 10.1002/alr.21344

    View details for PubMedID 24889751

  • Mucociliary clearance and submucosal gland secretion in the ex vivo ferret trachea. American journal of physiology. Lung cellular and molecular physiology Jeong, J. H., Joo, N. S., Hwang, P. H., Wine, J. J. 2014; 307 (1): L83-93

    Abstract

    In many species submucosal glands are an important source of tracheal mucus, but the extent to which mucociliary clearance (MCC) depends on gland secretion is unknown. To explore this relationship, we measured basal and agonist-stimulated MCC velocities in ex vivo tracheas from adult ferrets and compared the velocities with previously measured rates of ferret glandular mucus secretion (Cho HJ, Joo NS, Wine JJ. Am J Physiol Lung Cell Mol Physiol 299: L124-L136, 2010). Stimulated MCC velocities (mm/min, means ± SE for 10- to 35-min period poststimulation) were as follows: 1 μM carbachol: 19.1 ± 3.3 > 10 μM phenylephrine: 15.3 ± 2.4 ≈ 10 μM isoproterenol: 15.0 ± 1.9 ≈ 10 μM forskolin: 14.6 ± 3.1 > 1 μM vasoactive intestinal peptide (VIP): 10.2 ± 2.2 > basal (t15): 1.8 ± 0.3; n = 5-10 for each condition. Synergistic stimulation of MCC was observed between low concentrations of carbachol (100 nM) and isoproterenol (300 nM). Bumetanide inhibited carbachol-stimulated MCC by ~70% and abolished the increase in MCC stimulated by forskolin + VIP, whereas HCO3 (-)-free solutions did not significantly inhibit MCC to either intracellular Ca(2+) concentration or intracellular cAMP concentration ([cAMP]i)-elevating agonists. Stimulation and inhibition of MCC and gland secretion differed in several respects: most importantly, elevating [cAMP]i increased MCC much more effectively than expected from its effects on gland secretion, and bumetanide almost completely inhibited [cAMP]i-stimulated MCC while it had a smaller effect on gland secretion. We conclude that changes in glandular fluid secretion are complexly related to MCC and discuss possible reasons for this.

    View details for DOI 10.1152/ajplung.00009.2014

    View details for PubMedID 24793168

  • Update on evidence-based reviews with recommendations in adult chronic rhinosinusitis. International forum of allergy & rhinology Orlandi, R. R., Smith, T. L., Marple, B. F., Harvey, R. J., Hwang, P. H., Kern, R. C., Kingdom, T. T., Luong, A., Rudmik, L., Senior, B. A., Toskala, E., Kennedy, D. W. 2014; 4: S1-S15

    Abstract

    Chronic rhinosinusitis (CRS) has a significant impact not only on individuals who are afflicted but also on society as a whole. An increasing emphasis is being placed on incorporating the best available evidence into the care of patients, in association with an individual clinician's expertise and the patient's values. Recent evidence-based reviews with recommendations (EBRRs) have distilled our knowledge of CRS treatment options and have also pointed out continued gaps in this knowledge. This review synthesizes the findings of 8 EBRRs regarding CRS published in the International Forum of Allergy and Rhinology between 2011 and 2014. The recommendations in this review are based on the best available evidence and are meant to be incorporated into each patient's individual care, along with the practitioner's expertise and the individual patient's values and expectations. It is hoped that the EBRRs, and the process that spawned them, can provide the foundation for future guidelines in the diagnosis and management of CRS.

    View details for DOI 10.1002/alr.21344

    View details for PubMedID 24889751

  • Mucociliary clearance and submucosal gland secretion in the ex vivo ferret trachea AMERICAN JOURNAL OF PHYSIOLOGY-LUNG CELLULAR AND MOLECULAR PHYSIOLOGY Jeong, J. H., Joo, N. S., Hwang, P. H., Wine, J. J. 2014; 307 (1): L83-L93

    Abstract

    In many species submucosal glands are an important source of tracheal mucus, but the extent to which mucociliary clearance (MCC) depends on gland secretion is unknown. To explore this relationship, we measured basal and agonist-stimulated MCC velocities in ex vivo tracheas from adult ferrets and compared the velocities with previously measured rates of ferret glandular mucus secretion (Cho HJ, Joo NS, Wine JJ. Am J Physiol Lung Cell Mol Physiol 299: L124-L136, 2010). Stimulated MCC velocities (mm/min, means ± SE for 10- to 35-min period poststimulation) were as follows: 1 μM carbachol: 19.1 ± 3.3 > 10 μM phenylephrine: 15.3 ± 2.4 ≈ 10 μM isoproterenol: 15.0 ± 1.9 ≈ 10 μM forskolin: 14.6 ± 3.1 > 1 μM vasoactive intestinal peptide (VIP): 10.2 ± 2.2 > basal (t15): 1.8 ± 0.3; n = 5-10 for each condition. Synergistic stimulation of MCC was observed between low concentrations of carbachol (100 nM) and isoproterenol (300 nM). Bumetanide inhibited carbachol-stimulated MCC by ~70% and abolished the increase in MCC stimulated by forskolin + VIP, whereas HCO3 (-)-free solutions did not significantly inhibit MCC to either intracellular Ca(2+) concentration or intracellular cAMP concentration ([cAMP]i)-elevating agonists. Stimulation and inhibition of MCC and gland secretion differed in several respects: most importantly, elevating [cAMP]i increased MCC much more effectively than expected from its effects on gland secretion, and bumetanide almost completely inhibited [cAMP]i-stimulated MCC while it had a smaller effect on gland secretion. We conclude that changes in glandular fluid secretion are complexly related to MCC and discuss possible reasons for this.

    View details for DOI 10.1152/ajplung.00009.2014

    View details for Web of Science ID 000338923400008

  • Commentary on "How to avoid mucocele formation under pedicled nasoseptal flap". American journal of otolaryngology Vaezeafshar, R., Hwang, P. H., Turner, J. H. 2014; 35 (4): 547-?

    View details for DOI 10.1016/j.amjoto.2014.03.009

    View details for PubMedID 24815956

  • Outpatient endoscopic sinus surgery in cystic fibrosis patients: predictive factors for admission. International forum of allergy & rhinology Soudry, E., Mohabir, P. K., Miglani, A., Chen, J., Nayak, J. V., Hwang, P. H. 2014; 4 (5): 416-421

    Abstract

    An increasing number of adult patients with cystic fibrosis (CF) are becoming candidates for elective endoscopic sinus surgery (ESS). We sought to identify perioperative factors in this patient population that were predictive of postoperative admission.Retrospective chart review of CF patients who underwent ESS during the years 2005 through 2012. Multiple preoperative, intraoperative, and immediate postoperative variables were analyzed.Thirty-three patients who underwent 37 outpatient ESSs were identified. Successful same-day discharge was observed in 54%. In 46% of cases, postoperative admission was necessary, with a mean postoperative stay of 1.4 days. Pulmonary function, CF-related comorbidities, and history of lung transplant were not predictors of postoperative admission. Univariate analysis demonstrated that patients were more likely to be admitted if they had 1 of the following conditions: history of ≥4 prior ESS; procedure duration >2.5 hours; intraoperative blood loss greater than 150 mL; increased immediate postoperative pain scores; or larger narcotic requirements for pain control. On logistic regression analysis, a maximum pain score ≥ 7 out of 10 in the postanesthesia recovery unit was the only significant predisposing factor for postoperative admission.Although over 50% of adult CF patients can successfully undergo ESS on a same-day discharge basis, it is prudent to have contingent plans for potential inpatient observation postoperatively. Multivariate analysis suggests that preoperative demographics and pulmonary status cannot predict the need for postoperative admission, whereas higher pain scores in the postanesthesia care unit are predictive of the necessity for inpatient observation.

    View details for DOI 10.1002/alr.21285

    View details for PubMedID 24431198

  • Outpatient endoscopic sinus surgery in cystic fibrosis patients: predictive factors for admission INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Soudry, E., Mohabir, P. K., Miglani, A., Chen, J., Nayak, J. V., Hwang, P. H. 2014; 4 (5): 416-421

    Abstract

    An increasing number of adult patients with cystic fibrosis (CF) are becoming candidates for elective endoscopic sinus surgery (ESS). We sought to identify perioperative factors in this patient population that were predictive of postoperative admission.Retrospective chart review of CF patients who underwent ESS during the years 2005 through 2012. Multiple preoperative, intraoperative, and immediate postoperative variables were analyzed.Thirty-three patients who underwent 37 outpatient ESSs were identified. Successful same-day discharge was observed in 54%. In 46% of cases, postoperative admission was necessary, with a mean postoperative stay of 1.4 days. Pulmonary function, CF-related comorbidities, and history of lung transplant were not predictors of postoperative admission. Univariate analysis demonstrated that patients were more likely to be admitted if they had 1 of the following conditions: history of ≥4 prior ESS; procedure duration >2.5 hours; intraoperative blood loss greater than 150 mL; increased immediate postoperative pain scores; or larger narcotic requirements for pain control. On logistic regression analysis, a maximum pain score ≥ 7 out of 10 in the postanesthesia recovery unit was the only significant predisposing factor for postoperative admission.Although over 50% of adult CF patients can successfully undergo ESS on a same-day discharge basis, it is prudent to have contingent plans for potential inpatient observation postoperatively. Multivariate analysis suggests that preoperative demographics and pulmonary status cannot predict the need for postoperative admission, whereas higher pain scores in the postanesthesia care unit are predictive of the necessity for inpatient observation.

    View details for DOI 10.1002/alr.21285

    View details for Web of Science ID 000334895900013

    View details for PubMedID 24431198

  • Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Soudry, E., Turner, J. H., Nayak, J. V., Hwang, P. H. 2014; 150 (5): 730-738

    Abstract

    To systematically review the literature concerning techniques of closure of endoscopically created skull base defects based on site of skull base defect and flow rate of cerebrospinal fluid (CSF).PubMed, SCOPUS, and Cochrane databases.A comprehensive systematic literature review.The literature search produced a total of 1708 studies. Of these, 1585 studies were excluded based on title and/or abstract review. A total of 123 articles remained for full-text review, 101 of which were subsequently excluded primarily because of lack of detailed information as to the reconstructive techniques used or clinical outcomes. Of the 22 studies remaining for final analysis, all were case series. A total of 673 patients were included in the analysis, with an overall postoperative CSF leak rate of 8.5%. Subgroup analysis was performed based on location of the skull base defect and presence and quality of intraoperative CSF leak.Based on level 4 evidence, in cases of low-flow intraoperative CSF leaks, skull base reconstruction with multilayered free grafts and synthetic materials offers similar outcomes to vascularized flaps. In cases of high-flow intraoperative CSF leaks, pedicled vascularized flaps appear to be superior. Location of the defect does not seem to be a significant factor in determining successful closure, with the exception of clival defects. In all other sites, good closure may be achieved by multiple reconstructive approaches. More consistency in data reporting and higher levels of evidence will ultimately be necessary to make definitive recommendations.

    View details for DOI 10.1177/0194599814520685

    View details for PubMedID 24493791

  • Academic rhinology: a survey of residency programs and rhinology faculty in the United States. International forum of allergy & rhinology Tabaee, A., Chen, L., Smith, T. L., Hwang, P. H., Schaberg, M., Raithatha, R., Brown, S. M. 2014; 4 (4): 321-328

    Abstract

    Rhinology has rapidly evolved as a subspecialty over the past decade. The professional activities of rhinology faculty in otolaryngology residency programs is an important defining feature of this process but remains incompletely understood.An examination of faculty profiles of otolaryngology residency programs in the United States was performed to examine the professional activities of rhinologists. An anonymous, web-based survey of rhinology faculty was also performed to query professional activities and career satisfaction.Nine percent of chairmen and 12% of residency program directors were rhinologists. The number of full-time rhinology faculty members varied significantly among departments (mean 1; range, 0-4). Rhinology faculty members were noted to have a high number of scientific publications over the past 5 years (mean 15 per faculty), a high level of membership to the American Rhinologic Society (90%) and modest levels of membership to other societies. As reported by the 45 respondents who successfully completed the survey, higher percentages of professional time was devoted to clinical medicine when compared with administrative and research activities. Inflammatory sinusitis represented the most common clinical condition treated, and there was variability with respect to other disorders and procedures. Career satisfaction scores were highest for medical and surgical care, teaching activities, financial and emotional well being, and overall career to date. Lower satisfaction scores were noted for research and administrative activities and for balance of personal life with work.This study further defines the professional, clinical, and surgical activities of academic rhinologists. Continued analysis of the subspecialization of rhinology is required.

    View details for DOI 10.1002/alr.21268

    View details for PubMedID 24407909

  • Human ethmoid sinus mucosa: a promising novel tissue source of mesenchymal progenitor cells STEM CELL RESEARCH & THERAPY Cho, K., Park, H., Roh, H., Bravo, D. T., Hwang, P. H., Nayak, J. V. 2014; 5

    Abstract

    The identification of new progenitor cell sources is important for cell-based tissue engineering strategies, understanding regional tissue regeneration, and modulating local microenvironments and immune response. However, there are no reports that describe the identification and isolation of mesenchymal progenitor cells (MPCs) from paranasal sinus mucosa, and compare the properties of MPCs between tissue sources within the sinonasal cavity. We report here the identification of MPCs in the maxillary sinus (MS) and ethmoid sinus (ES). Furthermore, we contrast these MPCs in the same individuals with MPCs from two additional head and neck tissue sources of the inferior turbinate (IT) and tonsil (T).These four MPC sources were exhaustively compared for morphology, colony-forming potential, proliferation capability, immunophenotype, multilineage differentiation potential, and ability to produce soluble factors.MS-, ES, IT-, and T-MPCs showed similar morphologies and surface phenotypes, as well as adipogenic, osteogenic, and chondrogenic differentiation capacity by immunohistochemistry and qRT-PCR for defined lineage-specific genes. However, we noted that the colony-forming potential and proliferation capability of ES-MPCs were distinctly higher than other MPCs. All MPCs constitutively, or upon stimulation, secrete large amounts of IL-6, IL-8, IL-10, IFN-γ, and TGF-β. After stimulation with TNF-α and IFN-γ, ES-MPCs notably demonstrated significantly higher secretion of IL-6 and IL-10 than other MPCs.ES-MPCs may be a uniquely promising source of MPCs due to their high proliferation ability and superior capacity toward secretion of immunomodulatory cytokines.

    View details for DOI 10.1186/scrt404

    View details for Web of Science ID 000331727700003

    View details for PubMedCentralID PMC4055077

  • Endoscopic Hydroxyapatite Augmentation for Patulous Eustachian Tube LARYNGOSCOPE Vaezeafshar, R., Turner, J. H., Li, G., Hwang, P. H. 2014; 124 (1): 62-66

    Abstract

    To evaluate the safety and efficacy of endoscopic calcium hydroxyapatite injection in patients with patulous Eustachian tube.Retrospective case series.Fourteen patients diagnosed with patulous Eustachian tube (PET) underwent endoscopic hydroxyapatite injection under general anesthesia. All patients had at least two of three major PET symptoms including voice autophony, breathing autophony, or aural fullness/pressure. Patients were evaluated postoperatively with nasal endoscopy and a symptom questionnaire.Endoscopic Eustachian tube injection was performed in a total of 23 sides in 14 patients with an average volume of 2.1 cc injected per side. Mean follow-up was 17.5 months. The most common symptoms reported preoperatively were voice autophony (96%), breathing autophony (91%), and ear fullness (83%). A complete or significant response to treatment was noted in 13/22 sides with voice autophony (59%), 12/21 sides with breathing autophony (57%), and 12/19 sides with ear fullness (63%). All complete or significant symptom improvements remained durable through the entirety of the follow-up period. Four sides that had temporary or no improvement with treatment underwent repeat injection but did not achieve additional improvement. No intraoperative or postoperative complications were observed.Endoscopic hydroxyapatite injection of the Eustachian tube is a minimally invasive procedure that provided significant or complete relief of autophony and ear fullness in 57% to 63% of sides treated. The procedure is well tolerated and can be performed safely under endoscopic visualization. Hydroxyapatite injection may be a satisfactory alternative to more invasive treatments for PET.4. Laryngoscope, 2013.

    View details for DOI 10.1002/lary.24250

    View details for Web of Science ID 000328738800019

    View details for PubMedID 23775903

  • Endoscopic Resection of a Giant Intradural Retroclival Ecchordosis Physaliphora: Surgical Technique and Literature Review World Neurosurgery Choudhri, O., Feroze, A., Hwang, P., Vogel, H., Ajlan, A., Harsh IV, G. 2014: 912.e21–6

    Abstract

    To report the first complete resection of a giant ecchordosis physaliphora using an endoscopic transclival approach and to provide a current review of the literature.This rare benign lesion, originating from embryonic notochordal remnants, was located in the prepontine cistern of a 63-year-old man presenting with progressive tremor and imbalance. Preoperative imaging demonstrated a 2.1-cm intradural lesion abutting the pons and basilar artery and extending through the dura mater.A gross total resection was successfully achieved endoscopically without neurovascular compromise or additional complications. Postoperative histopathologic examination was consistent with a diagnosis of giant ecchordosis physaliphora.An endoscopic endonasal transclival approach provided a direct, minimally invasive route for safe and complete resection of this rare prepontine tumor, as it has for similarly located skull base chordomas. Our experience highlights the utility of endoscopy in visualization of both pathologic entities and nearby critical neurovascular structures in the management of ecchordosis physaliphora and other cranial base neoplasms.

    View details for DOI 10.1016/j.wneu.2014.06.019

  • Otolaryngology, Head and Neck Surgery BIOMED RESEARCH INTERNATIONAL Yang, T., Ferris, R. L., Ogawa, T., Hwang, P., Tong, M., Chen, M. 2014: 625601

    View details for PubMedID 25610869

    View details for PubMedCentralID PMC4290898

  • Nasal Microenvironments and Interspecific Interactions Influence Nasal Microbiota Complexity and S. aureus Carriage. Cell host & microbe Yan, M., Pamp, S. J., Fukuyama, J., Hwang, P. H., Cho, D., Holmes, S., Relman, D. A. 2013; 14 (6): 631-640

    Abstract

    The indigenous microbiota of the nasal cavity plays important roles in human health and disease. Patterns of spatial variation in microbiota composition may help explain Staphylococcus aureus colonization and reveal interspecies and species-host interactions. To assess the biogeography of the nasal microbiota, we sampled healthy subjects, representing both S. aureus carriers and noncarriers at three nasal sites (anterior naris, middle meatus, and sphenoethmoidal recess). Phylogenetic compositional and sparse linear discriminant analyses revealed communities that differed according to site epithelium type and S. aureus culture-based carriage status. Corynebacterium accolens and C. pseudodiphtheriticum were identified as the most important microbial community determinants of S. aureus carriage, and competitive interactions were only evident at sites with ciliated pseudostratified columnar epithelium. In vitro cocultivation experiments provided supporting evidence of interactions among these species. These results highlight spatial variation in nasal microbial communities and differences in community composition between S. aureus carriers and noncarriers.

    View details for DOI 10.1016/j.chom.2013.11.005

    View details for PubMedID 24331461

  • Pretreatment of sinus aspirates with dithiothreitol improves yield of fungal cultures in patients with chronic sinusitis. International forum of allergy & rhinology Chisholm, K. M., Getsinger, D., Vaughan, W., Hwang, P. H., Banaei, N. 2013; 3 (12): 992-996

    Abstract

    Mold pathogens are a leading cause of chronic rhinosinusitis. Successful isolation of mold on culture is helpful in establishing a diagnosis and guiding therapy. Though mucolytic agents are commonly used in European countries, they are not part of everyday use in North America. In this case-control prospective study, we investigated the yield of fungal culture before and after treatment of sinus aspirates with the mucolytic agent dithiothreitol in a United States hospital.Over a 5-month period during 2011-2012, 359 sinus aspirates from 294 patients with symptoms suspicious for chronic sinusitis or allergic fungal sinusitis were collected. Aspirates were cultured on fungal medium before and after treatment with dithiothreitol.Of the 359 pairs of cultures, 62 (17.3%) demonstrated mold growth on at least 1 of the plates, 9 (14.5%) of which grew more than 1 species of mold. A total of 75 molds were identified, 41 (54.7%) of which were successfully cultured only when the mucus was pretreated with dithiothreitol (p < 0.0001). Quantitatively, more colonies grew from dithiothreitol-treated mucus than from direct-inoculation (p < 0.0001).This study confirms improved recovery of mold from sinus cultures after pretreatment of samples with dithiothreitol. Further studies are needed to correlate these findings with clinical outcome.

    View details for DOI 10.1002/alr.21230

    View details for PubMedID 24124079

  • Pretreatment of sinus aspirates with dithiothreitol improves yield of fungal cultures in patients with chronic sinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Chisholm, K. M., Getsinger, D., Vaughan, W., Hwang, P. H., Banaei, N. 2013; 3 (12): 992-996

    Abstract

    Mold pathogens are a leading cause of chronic rhinosinusitis. Successful isolation of mold on culture is helpful in establishing a diagnosis and guiding therapy. Though mucolytic agents are commonly used in European countries, they are not part of everyday use in North America. In this case-control prospective study, we investigated the yield of fungal culture before and after treatment of sinus aspirates with the mucolytic agent dithiothreitol in a United States hospital.Over a 5-month period during 2011-2012, 359 sinus aspirates from 294 patients with symptoms suspicious for chronic sinusitis or allergic fungal sinusitis were collected. Aspirates were cultured on fungal medium before and after treatment with dithiothreitol.Of the 359 pairs of cultures, 62 (17.3%) demonstrated mold growth on at least 1 of the plates, 9 (14.5%) of which grew more than 1 species of mold. A total of 75 molds were identified, 41 (54.7%) of which were successfully cultured only when the mucus was pretreated with dithiothreitol (p < 0.0001). Quantitatively, more colonies grew from dithiothreitol-treated mucus than from direct-inoculation (p < 0.0001).This study confirms improved recovery of mold from sinus cultures after pretreatment of samples with dithiothreitol. Further studies are needed to correlate these findings with clinical outcome.

    View details for DOI 10.1002/alr.21230

    View details for Web of Science ID 000328300500008

    View details for PubMedID 24124079

  • Systemic prednisone administration selectively alters granulocyte subsets in nasal polyps from aspirin-exacerbated respiratory disease and chronic rhinosinusitis patients. International forum of allergy & rhinology Edward, J. A., Sanyal, M., Ramakrishnan, V. R., Le, W., Nguyen, A. L., Kingdom, T. T., Hwang, P. H., Nayak, J. V. 2013; 3 (11): 866-876

    Abstract

    Nasal polyps (NPs) are hallmark inflammatory lesions of sinusitis. Despite the spectrum of NP conditions, cellular differences between NPs from patients with chronic rhinosinusitis with NPs (CRSwNP) and aspirin-exacerbated respiratory disease (AERD) are poorly understood. NPs are associated with abundant eosinophils; the contributions of neutrophil and basophil granulocytes are less defined. We therefore sought to assess granulocyte subpopulations, and differential effects following prednisone pretreatment, within NPs of CRSwNP and AERD patients.NPs, adjacent ethmoid sinus tissue, and peripheral blood mononuclear cells (PBMCs) were obtained from patients undergoing endoscopic sinus surgery. Samples from 5 cohorts: CRSwNP ± prednisone (n = 6 each), AERD ± prednisone (n = 6 each), and controls (n = 9), were analyzed by high-dimensional flow cytometry to gate granulocyte populations. Specimens were also assessed using immunohistochemistry (IHC) staining.Systemic prednisone administration was associated with a lower frequency of eosinophils (p < 0.0001, n = 6) in NPs in both CRSwNP and AERD patients, whereas a decrease in neutrophils (p = 0.0070, n = 6) in NPs was only observed in CRSwNP patients after prednisone treatment. In contrast, steroids do not alter basophil proportions (p = 0.48, n = 6) within NPs from either group. No significant shift in granulocyte subsets after steroid treatment was identified in the adjacent ethmoid mucosa or PBMCs from the same patients. Immunohistochemistry (IHC) staining supported these findings.Granulocyte subpopulations are focally affected within NPs by systemic steroid exposure, without notable granulocyte alterations in the surrounding regional tissues. These data provide direct insights into the cellular effects of routine prednisone exposure in CRS patients, and highlight a unique microenvironment present within NP lesions.

    View details for DOI 10.1002/alr.21221

    View details for PubMedID 24106221

  • Systemic prednisone administration selectively alters granulocyte subsets in nasal polyps from aspirin-exacerbated respiratory disease and chronic rhinosinusitis patients. International forum of allergy & rhinology Edward, J. A., Sanyal, M., Ramakrishnan, V. R., Le, W., Nguyen, A. L., Kingdom, T. T., Hwang, P. H., Nayak, J. V. 2013; 3 (11): 866-876

    View details for DOI 10.1002/alr.21221

    View details for PubMedID 24106221

  • Patient-Centered Decision Making in the Treatment of Chronic Rhinosinusitis LARYNGOSCOPE Soler, Z. M., Rudmik, L., Hwang, P. H., Mace, J. C., Schlosser, R. J., Smith, T. L. 2013; 123 (10): 2341-2346

    Abstract

    To explore possible factors that might impact a patient's choice to pursue endoscopic sinus surgery (ESS) or continue with medical management for treatment of refractory chronic rhinosinusitis (CRS).Cross-sectional evaluation of a multicenter prospective cohort.Two hundred forty-two subjects with CRS were prospectively enrolled within four academic tertiary care centers across North America with ongoing symptoms despite prior medical treatment. Subjects either self-selected continued medical management (n = 62) or ESS (n = 180) for treatment of sinonasal symptoms. Differences in demographics, comorbid conditions, and clinical measures of disease severity between subject groups were compared. Validated metrics of social support, personality, risk aversion, and physician-patient relationships were compared using bivariate analyses, predicted probabilities, and receiver operating characteristic curves at the 0.05 alpha level.No significant differences were found between treatment groups for any demographic characteristic, clinical cofactor, or measure of social support, personality, or the physician-patient relationship. Subjects electing to pursue sinus surgery did report significantly worse average quality-of-life (QOL) scores on the 22-item Sinonasal Outcome Test (SNOT-22; P < .001) compared to those electing continued medical therapy (54.6 ± 18.9 vs. 39.4 ± 17.7), regardless of surgical history or polyp status. SNOT-22 score significantly predicted treatment selection (odds ratio, 1.046; 95% confidence interval, 1.028-1.065; P < .001) and was found to accurately discriminate between subjects choosing endoscopic sinus surgery and those electing medical management 72% of the time.Worse patient-reported disease severity, as measured by the SNOT-22, was significantly associated with the treatment choice for CRS. Strong consideration should be given for incorporating CRS-specific QOL measures into routine clinical practice.2b. Laryngoscope, 2013.

    View details for DOI 10.1002/lary.24027

    View details for Web of Science ID 000325091100005

    View details for PubMedID 23856802

  • REORGANIZATION OF LOCALIZATION OF DUOX1 AND DUOX2 IN CF PATIENT AIRWAYS Hanna, B., Bravo, D., Illek, B., Cho, D. Y., Hwang, P., Nayak, J., Fischer, H. WILEY-BLACKWELL. 2013: 261–62
  • Characterization of human upper airway epithelial progenitors. International forum of allergy & rhinology Bravo, D. T., Soudry, E., Edward, J. A., Le, W., Nguyen, A. L., Hwang, P. H., Sanyal, M., Nayak, J. V. 2013; 3 (10): 841-847

    Abstract

    New epithelial cells are generated through the proliferation and differentiation of resident progenitor cells in the nasal cavity. In several upper airway diseases, such as cystic fibrosis and chronic rhinosinusitis, self-renewing progenitor cells may be functionally defective, or compromised in their ability, to regenerate cells that maintain normal mucociliary clearance. Herein, we describe our early work to define and characterize a rare population of human nasal epithelial putative progenitors.Single-cell suspensions of human ethmoid sinus tissues were prepared following endoscopic sinus surgery. Cell surface antibodies were analyzed as candidate markers for detecting progenitor cells. A panel of antibodies, including epithelial cell adhesion molecule (EpCAM, epithelial cells), CD45 (hematopoietic cells), nerve growth factor receptor (NGFR/CD271), intercellular adhesion molecule-1 (ICAM1/CD54), and integrin-α6 (ITGA6/CD49f) were used to resolve epithelial progenitor candidates by high-dimensional flow cytometry and the gating technique of fluorescence minus one (FMO) controls.A rare population of approximately 0.06% of total ethmoid cells was discriminated as EpCAM(-) CD45(-) NGFR(+) ICAM1(+) by surface markers. Use of ITGA6 was excluded based on FMO control analysis. This lineage-negative population was purified to 99% homogeneity by cell sorting and analyzed by immunofluorescence microscopy. Sorted cells were subsequently confirmed to uniformly express the transcription factor p63. Upon in vitro culture, lineage-negative clonal cells were confirmed to spontaneously differentiate into epithelial lineage-positive cells.Using the NGFR and ICAM1 cellular coordinates, we have identified a promising population of native human nasal epithelial progenitor cells that require more formal investigation for their role in upper airway regeneration.

    View details for DOI 10.1002/alr.21205

    View details for PubMedID 23901007

  • Characterization of human upper airway epithelial progenitors. International forum of allergy & rhinology Bravo, D. T., Soudry, E., Edward, J. A., Le, W., Nguyen, A. L., Hwang, P. H., Sanyal, M., Nayak, J. V. 2013; 3 (10): 841-847

    Abstract

    New epithelial cells are generated through the proliferation and differentiation of resident progenitor cells in the nasal cavity. In several upper airway diseases, such as cystic fibrosis and chronic rhinosinusitis, self-renewing progenitor cells may be functionally defective, or compromised in their ability, to regenerate cells that maintain normal mucociliary clearance. Herein, we describe our early work to define and characterize a rare population of human nasal epithelial putative progenitors.Single-cell suspensions of human ethmoid sinus tissues were prepared following endoscopic sinus surgery. Cell surface antibodies were analyzed as candidate markers for detecting progenitor cells. A panel of antibodies, including epithelial cell adhesion molecule (EpCAM, epithelial cells), CD45 (hematopoietic cells), nerve growth factor receptor (NGFR/CD271), intercellular adhesion molecule-1 (ICAM1/CD54), and integrin-α6 (ITGA6/CD49f) were used to resolve epithelial progenitor candidates by high-dimensional flow cytometry and the gating technique of fluorescence minus one (FMO) controls.A rare population of approximately 0.06% of total ethmoid cells was discriminated as EpCAM(-) CD45(-) NGFR(+) ICAM1(+) by surface markers. Use of ITGA6 was excluded based on FMO control analysis. This lineage-negative population was purified to 99% homogeneity by cell sorting and analyzed by immunofluorescence microscopy. Sorted cells were subsequently confirmed to uniformly express the transcription factor p63. Upon in vitro culture, lineage-negative clonal cells were confirmed to spontaneously differentiate into epithelial lineage-positive cells.Using the NGFR and ICAM1 cellular coordinates, we have identified a promising population of native human nasal epithelial progenitor cells that require more formal investigation for their role in upper airway regeneration.

    View details for DOI 10.1002/alr.21205

    View details for PubMedID 23901007

  • Distribution of topical agents to the paranasal sinuses: an evidence-based review with recommendations INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Thomas, W. W., Harvey, R. J., Rudmik, L., Hwang, P. H., Schlosser, R. J. 2013; 3 (9): 691-703

    Abstract

    BACKGROUND: The objective of this work was to review the literature concerning the distribution of topical therapeutics to the sinuses versus nasal cavity regarding: surgical state, delivery device, head position, and nasal anatomy and to provide evidence-based recommendations. METHODS: A systematic review was conducted using Medline, EMBASE, and Cochrane databases to perform a Medical Subject Heading search of the literature from 1946 until the last week of May 2012. Articles were independently reviewed and graded for level of evidence. All authors came to consensus on recommendations through an iterative process. RESULTS: Recommendations were made for: improved sinus delivery with high-volume devices and after standard sinus surgery. Recommendations were made against low-volume delivery devices, such as drops, sprays, or simple nebulizers as they do not reliably reach the sinuses. If large-volume devices are not tolerated, low-volume devices are recommended using the lying head back or lateral head low positions to improve nasal cavity distribution to the middle meatus or olfactory cleft. CONCLUSION: Surgery, volume of device, head position, and nasal anatomy were shown to impact distribution to the sinuses. Recommendations are made based upon this evidence as to how to best maximize therapeutic distribution to the sinuses.

    View details for DOI 10.1002/alr.21172

    View details for Web of Science ID 000325111500002

    View details for PubMedID 23729216

  • Survival outcomes in acute invasive fungal sinusitis: A systematic review and quantitative synthesis of published evidence. Laryngoscope Turner, J. H., Soudry, E., Nayak, J. V., Hwang, P. H. 2013; 123 (5): 1112-1118

    Abstract

    Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. The current study systematically reviews and quantitatively synthesizes the published literature to characterize prognostic factors associated with survival.Systematic review.Fifty-two studies comprising a total of 807 patients met inclusion criteria and were used for analysis of treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors.All studies were classified as level 4 evidence, as per definitions provided by the Oxford Center for Evidence-Based Medicine. The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall survival rate was 49.7%. On univariate analysis, poor prognosis was associated with renal/liver failure, altered mental status, and intracranial extension. Patients who were diabetic, had surgery, or received liposomal amphotericin B had an improved chance of survival. On multivariate analysis, advanced age and intracranial involvement were identified as independent negative prognostic factors. Positive prognostic factors again included diabetes and surgical resection.The overall mortality of patients with AIFS remains high, with only half of the patients surviving. Diabetic patients appear to have a better overall survival than patients with other comorbidities. Patients who have intracranial involvement, or who do not receive surgery as part of their therapy, have a poor prognosis.N/A.

    View details for DOI 10.1002/lary.23912

    View details for PubMedID 23300010

  • Expression of dual oxidases and secreted cytokines in chronic rhinosinusitis. International forum of allergy & rhinology Cho, D., Nayak, J. V., Bravo, D. T., Le, W., Nguyen, A., Edward, J. A., Hwang, P. H., Illek, B., Fischer, H. 2013; 3 (5): 376-383

    View details for DOI 10.1002/alr.21133

    View details for PubMedID 23281318

  • Expression of dual oxidases and secreted cytokines in chronic rhinosinusitis. International forum of allergy & rhinology Cho, D., Nayak, J. V., Bravo, D. T., Le, W., Nguyen, A., Edward, J. A., Hwang, P. H., Illek, B., Fischer, H. 2013; 3 (5): 376-383

    Abstract

    The airway epithelium generates reactive oxygen species (ROS) as a first line of defense. Dual oxidases (DUOX1 and DUOX2) are the H2 O2 -producing isoforms of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase family in the airway epithelium. The purpose of this study was to explore the molecular expression, function, and regulation of DUOXs in chronic rhinosinusitis (CRS).Human nasal tissue samples and nasal secretions were collected from 3 groups of patients undergoing sinus surgery (normal, n = 7; CRS with polyposis [CRSwP], n = 6; CRS without polyposis [CRSsP], n = 6). Nasal secretions were studied for cytokine and H2 O2 content. Tissue samples were used to determine DUOX mRNA and protein expression.DUOX1 mRNA level (80.7 ± 60.5) was significantly increased in CRSwP compared to normal (2.7 ± 1.2) and CRSsP (2.3 ± 0.5, p = 0.042). DUOX2 mRNA levels were increased in both CRSwP (18.6 ± 9.9) and CRSsP (4.0 ± 1.3) compared to normal (1.1 ± 0.3; p = 0.008). DUOX protein was found in the apical portion of the nasal epithelium and protein expression was increased in CRSwP and CRSsP. H2 O2 production was significantly higher in CRSwP (160.9 ± 59.4 nM) and CRSsP (81.7 ± 5.6 nM) compared to normal (53.5 ± 11.5 nM, p = 0.032). H2 O2 content of nasal secretions correlated tightly with DUOX expression (p < 0.001). Cytokines (eotaxin, monokine-induced by interferon γ [MIG], tumor necrosis factor [TNF]-α, interleukin [IL]-8) showed significantly higher levels in nasal secretions from CRSwP compared to normal (p < 0.05). Levels of eotaxin, MIG, and TNF-α correlated closely with DUOX expression.DUOX1 and DUOX2 were identified as factors upregulated in CRS. Close correlations between DUOX expression and H2 O2 release, and correlation between key inflammatory cytokines and DUOX expression, indicate DUOX in the inflammatory response in CRS.

    View details for DOI 10.1002/alr.21133

    View details for PubMedID 23281318

  • Endoscopic endonasal anatomy of the nasopharynx in a cadaver model INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Becker, A. M., Hwang, P. H. 2013; 3 (4): 319-324

    Abstract

    Nasopharyngectomy is an accepted treatment for recurrent nasopharyngeal carcinoma following radiation with or without chemotherapy. Traditionally, the nasopharynx has been approached through relatively invasive "open" techniques including transpalatal, maxillary swing, and trans-mandibular-pterygoid approaches. Contemporary management has included the use of endoscopic techniques to exenterate tumors in this location. The purpose of the present study is to describe the endoscopic anatomy of this region through cadaveric dissection and to characterize the technical limitations of the approach.Five fresh cadaveric heads were dissected to study the endoscopic anatomy of the nasopharynx and associated structures.Endoscopic dissection of the nasopharynx was completed in all 5 specimens. Nasopharyngeal anatomy including the buccopharyngeal fascia, pharyngobasilar fascia, superior constrictor, longus capitus, longus coli, fossa of Rosenmuller, basisphenoid, auditory torus, and internal carotid artery were characterized.Surgical access to the nasopharynx has posed significant challenges in the treatment of recurrent or persistent nasopharyngeal carcinoma. This study demonstrated that endoscopic dissection of this region is feasible and has the potential to completely exenterate these lesions.

    View details for DOI 10.1002/alr.21104

    View details for Web of Science ID 000317362900010

    View details for PubMedID 23109510

  • Basal lamella relaxing incision improves endoscopic middle meatal access INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Getz, A. E., Hwang, P. H. 2013; 3 (3): 231-235

    Abstract

    Lateralization of the middle turbinate is a commonly cited factor leading to failure of functional endoscopic sinus surgery (FESS). Inadequate medialization during FESS may require repeat intraoperative attempts, and may lead to destabilization and mucosal trauma. A novel technique is described that increases middle meatal area and provides more definitive medialization at the outset of FESS.Twenty-nine middle turbinate medializations were prospectively evaluated in 18 consecutive patients undergoing primary ESS. Three intraoperative images of the middle meatus were obtained in the native position, after Freer medialization, and after basal lamella relaxing incision (BLRI). Measurements of middle meatal area were then calculated in a blinded and randomized fashion.Distances measured from the middle turbinate to the lateral nasal wall for each position ranged from 0 to 8 mm (median = 3.00 mm) for the native position, 0.5 to 10 mm (median = 5.00 mm) for standard Freer medialization, and 3 to 21 mm (median = 10.00 mm) for BLRI. Friedman's analysis of variance (ANOVA) showed that there was significant difference between the 3 measurements, and the post hoc Wilcoxon signed ranks tests showed that BLRI distance (median = 10; 95% confidence interval [CI], 7-11.2) was significantly larger than both standard Freer (median = 5; 95% CI, 4-6.2) and native (median = 3; 95% CI, 2-3) and that standard Freer was significantly larger than native (all p values <0.001).BLRI is a safe, controlled technique that provides significantly greater medialization of the middle turbinate compared to standard medialization techniques. BLRI significantly enhances the operative space within the middle meatus.

    View details for DOI 10.1002/alr.21086

    View details for Web of Science ID 000316265000012

    View details for PubMedID 23038164

    View details for PubMedCentralID PMC3584187

  • Trends in incidence and susceptibility among methicillin-resistant Staphylococcus aureus isolated from intranasal cultures associated with rhinosinusitis. American journal of rhinology & allergy Rujanavej, V., Soudry, E., Banaei, N., Baron, E. J., Hwang, P. H., Nayak, J. V. 2013; 27 (2): 134-137

    Abstract

    Reports regarding the incidence and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) in rhinosinusitis (RS) are limited. This study was designed to identify epidemiology and trends of MRSA incidence and antimicrobial resistance in the sinonasal cavities.This is a retrospective case series. All intranasal/sinus cultures obtained by otolaryngologists at Stanford over a 20-year period (1990-2010) were retrospectively reviewed by mining the microbiology database. Nested searches were then made for all S. aureus and MRSA cultures. Patterns of incidence and changes in antibiotic susceptibilities were tabulated and statistical analysis was performed.Our search retrieved 10,387 positive intranasal culture samples, with S. aureus found in 800 (7.7%), and MRSA comprising 110 (1.06%) of this subset. Between the years of 1990 and 1999, only 2/112 (1.7%) of S. aureus-positive nasal cultures were positive for MRSA, with a sharp rise in incidence to 86/606 (14.2%) from 2000 to 2005, and to 22/82, 26.8% from 2006 to 2010. On a percent basis, using logistic regression modeling, this represents a statistically significant increasing trend (p < 0.0001) for MRSA sinusitis. However, over the 20-year interval studied, the patterns of antibiotic resistance among MRSA remained unaltered, especially with regard to trimethoprim-sulfamethoxazole and vancomycin.S. aureus and MRSA isolates from intranasal cultures, which were essentially absent before the year 2000, became significantly more common earlier this decade. These data show the increased role of MRSA in sinusitis. MRSA antibiotic susceptibilities have remained, however, largely stable during this time period.

    View details for DOI 10.2500/ajra.2013.27.3858

    View details for PubMedID 23562203

  • Trends in incidence and susceptibility among methicillin-resistant Staphylococcus aureus isolated from intranasal cultures associated with rhinosinusitis. American journal of rhinology & allergy Rujanavej, V., Soudry, E., Banaei, N., Baron, E. J., Hwang, P. H., Nayak, J. V. 2013; 27 (2): 134-137

    Abstract

    Reports regarding the incidence and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) in rhinosinusitis (RS) are limited. This study was designed to identify epidemiology and trends of MRSA incidence and antimicrobial resistance in the sinonasal cavities.This is a retrospective case series. All intranasal/sinus cultures obtained by otolaryngologists at Stanford over a 20-year period (1990-2010) were retrospectively reviewed by mining the microbiology database. Nested searches were then made for all S. aureus and MRSA cultures. Patterns of incidence and changes in antibiotic susceptibilities were tabulated and statistical analysis was performed.Our search retrieved 10,387 positive intranasal culture samples, with S. aureus found in 800 (7.7%), and MRSA comprising 110 (1.06%) of this subset. Between the years of 1990 and 1999, only 2/112 (1.7%) of S. aureus-positive nasal cultures were positive for MRSA, with a sharp rise in incidence to 86/606 (14.2%) from 2000 to 2005, and to 22/82, 26.8% from 2006 to 2010. On a percent basis, using logistic regression modeling, this represents a statistically significant increasing trend (p < 0.0001) for MRSA sinusitis. However, over the 20-year interval studied, the patterns of antibiotic resistance among MRSA remained unaltered, especially with regard to trimethoprim-sulfamethoxazole and vancomycin.S. aureus and MRSA isolates from intranasal cultures, which were essentially absent before the year 2000, became significantly more common earlier this decade. These data show the increased role of MRSA in sinusitis. MRSA antibiotic susceptibilities have remained, however, largely stable during this time period.

    View details for DOI 10.2500/ajra.2013.27.3858

    View details for PubMedID 23562203

  • Staph aureus has long been recognized as being more prevalent in cultures from patients with chronic rhinosinusitis(CRS) compared to those with acute rhinosinusitis. International forum of allergy & rhinology Hwang, P. H. 2013; 3 (2): 81-82

    View details for DOI 10.1002/alr.21155

    View details for PubMedID 23413117

  • Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Poetker, D. M., Jakubowski, L. A., Lal, D., Hwang, P. H., Wright, E. D., Smith, T. L. 2013; 3 (2): 104-120

    Abstract

    Oral steroids are commonly used in the management of chronic rhinosinusitis (CRS) with and without nasal polyps (CRSwNP and CRSsNP, respectively). Past reports have included evaluation of the evidence for the use of oral steroids in CRS subtypes. However, a review with evidence-based recommendations for all CRS subtypes has never been performed. The purpose of this article is to provide a comprehensive, evidence-based approach for the utilization of oral steroids in the management of CRS.A systematic review of the literature was performed following recommendations of the Clinical Practice Guideline Manual, Conference on Guideline Standardization, and Appraisal of Guidelines and Research Evaluation. Inclusion criteria were: adult population ≥ 18 years old; CRS; oral steroids as the treatment group; and clearly defined primary clinical end-point.This review identified and evaluated the literature on the use of oral steroids for CRSwNP, CRSsNP, allergic fungal sinusitis (AFS), and the use of oral steroids in the perioperative period in these patients. Recommendations based on evidence, benefit/harm assessment, and value judgments are made.Oral steroids are strongly recommended for short-term management of CRSwNP. Oral steroids are also recommended for management of AFS. Oral steroid use in CRSsNP is optional due to insufficient strong evidence. Oral steroids are also strongly recommended in the perioperative period for CRSwNP and AFS. There is no recommendation for oral steroids use in the perioperative period in patients with CRSsNP. The risks of oral steroids are rare, but significant adverse effects must be considered.

    View details for DOI 10.1002/alr.21072

    View details for Web of Science ID 000315141700006

    View details for PubMedID 22887970

  • The endoscopic-assisted trephination approach for repair of frontal sinus cerebrospinal fluid leaks LARYNGOSCOPE Crozier, D. L., Hwang, P. H., Goyal, P. 2013; 123 (2): 321-325

    View details for DOI 10.1002/lary.23499

    View details for Web of Science ID 000314985400006

    View details for PubMedID 22952018

  • Balloon Dilation of the Sinuses ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Hwang, P. H. 2012; 138 (11): 1077-1079

    View details for Web of Science ID 000312400100012

    View details for PubMedID 23165383

  • Interrater agreement of nasal endoscopy in patients with a prior history of endoscopic sinus surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY McCoul, E. D., Smith, T. L., Mace, J. C., Anand, V. K., Senior, B. A., Hwang, P. H., Stankiewicz, J. A., Tabaee, A. 2012; 2 (6): 453-459

    Abstract

    Nasal endoscopy is an important part of the clinical evaluation of patients with chronic rhinosinusitis. However, the objectivity and interrater agreement of the procedure related findings have not been well studied, especially in patients who have previously had sinus surgery.Patients with a history of endoscopic sinus surgery for chronic rhinosinusitis were prospectively enrolled from a tertiary rhinology practice. Fourteen endoscopic nasal examinations were recorded using digital video capture software. Each patient also underwent computed tomography (CT) and completed the Sinonasal Outcome Test (SNOT-22). Blinded review of inflammatory and anatomic findings for each video was independently performed by 5 academic rhinologists at separate institutions. Comparisons were performed using the unweighted Fleiss' kappa statistic (K(f) ) and the prevalence- and bias-adjusted kappa (PABAK).There were no significant correlations between age, Lund-Mackay score, or SNOT-22 score. Interrater agreement was variable across the characteristics studied. Mean PABAK was excellent for the assessment of polyps (K(f) = 0.886); moderate for the assessments of middle turbinate (MT) integrity (K(f) = 0.543), MT position (K(f) = 0.443), maxillary sinus patency (K(f) = 0.593), and ethmoid sinus patency (K(f) = 0.429); fair for discharge (K(f) = 0.314), synechiae (K(f) = 0.257), and middle meatus patency (K(f) = 0.229); and poor for MT mucosal changes (K(f) = 0.148) and uncinate process (K(f) = 0.126).This study was notable for variability in the interrater agreement among the inflammatory and anatomic attributes that were examined. Further standardization of nasal endoscopy with regard to interpretation may improve the reliability of this procedure in clinical practice.

    View details for DOI 10.1002/alr.21058

    View details for Web of Science ID 000312142200004

    View details for PubMedID 22696506

    View details for PubMedCentralID PMC3448826

  • Mucocele formation under pedicled nasoseptal flap AMERICAN JOURNAL OF OTOLARYNGOLOGY Vaezeafshar, R., Hwang, P. H., Harsh, G., Turner, J. H. 2012; 33 (5): 634-636

    Abstract

    The pedicled nasoseptal flap has become an indispensible tool for the reconstruction of skull base defects. This flap is easily harvested, provides a large surface area of vascularized tissue, and has few reported complications. We describe the case of a 60-year-old man who underwent endoscopic, endonasal transsphenoidal surgery with septal flap reconstruction who developed a sphenoid sinus mucocele postoperatively. We also have reviewed the literature for similar findings and discuss this complication in the setting of pituitary surgery and endoscopic skull base repair. Although likely a rare occurrence, mucocele formation after septal flap reconstruction should be recognized and monitored with postoperative nasal endoscopy and radiologic imaging. Reoperation or mucocele drainage may be necessary if symptomatic or in cases of rapid enlargement.

    View details for DOI 10.1016/j.amjoto.2012.05.003

    View details for Web of Science ID 000308833800028

    View details for PubMedID 22771247

  • Low-frequency pulsed ultrasound in the nasal cavity and paranasal sinuses: a feasibility and distribution study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Patel, Z. M., Hwang, P. H., Chernomorsky, A., Bravo, D. T., Nguyen, B. L., Nesterova, K., Nayak, J. V. 2012; 2 (4): 303-308

    Abstract

    Bacterial biofilms have been implicated in refractory rhinosinusitis. Biofilms have been shown to respond to treatment with low-frequency ultrasound (LFU) therapy in vitro, and exposure to LFU has shown efficacy in wound repair and topical drug delivery in other fields. This preliminary study was designed to evaluate the safety and feasibility of LFU for use in the nasal cavity and paranasal sinuses.This was an experimental observational study. Six cadaver heads were used to deliver a mixture of Renografin and methylene blue solvent to the paranasal sinuses via LFU both before and after resident endoscopic sinus dissection. Sinus computed tomography (CT) scans of the cadaver heads were performed before and after mixture delivery, and blinded assessments were made for distribution to individual sinuses. Mucosa was harvested from 2 subsites to evaluate LFU-treated cadaver tissue.Predissection, LFU delivered solution to 12 of 12 inferior and middle turbinates, 6 of 12 of the superior turbinates and ethmoid sinuses, and 1 of 12 maxillary sinuses as shown by contrast radiography. Postdissection, all heads showed delivery to the maxillary and sphenoid sinuses, with 8 of 12 sinus cavities showing delivery to the ethmoid region, and 4 of 11 to the frontal recess. Using hematoxylin and eosin (H&E) staining of tissue frozen sections, harvested tissue demonstrated no architectural damage to the mucosal layer from LFU exposure.LFU appears to be capable of reliably delivering topical solution to the turbinates and ethmoid region preoperatively and to all sinuses, except the frontal, postoperatively. The nasal epithelium does not appear to be disrupted histologically from LFU at this time and distance. This data provides a foundation for a prospective human protocol studying the efficacy of this modality in the treatment of patients with chronic rhinosinusitis and biofilm formation.

    View details for DOI 10.1002/alr.21039

    View details for PubMedID 22528624

  • Epigenetic modifications and improved regulatory T-cell function in subjects undergoing dual sublingual immunotherapy JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY Swamy, R. S., Reshamwala, N., Hunter, T., Vissamsetti, S., Santos, C. B., Baroody, F. M., Hwang, P. H., Hoyte, E. G., Garcia, M. A., Nadeau, K. C. 2012; 130 (1): 215-?

    Abstract

    Allergen-specific immunotherapy is the only mode of therapy that has been demonstrated to offer a cure in patients with IgE-mediated respiratory allergies.We sought to demonstrate the safety and efficacy of timothy grass (TG) and dust mite (DM) dual sublingual immunotherapy (SLIT) and to begin to investigate the immune mechanisms involved in successful immunotherapy with multiple allergens.The safety and efficacy of dual SLIT with TG and DM in children and adults with demonstrated allergies to TG and DM were investigated in a single-center, randomized, double-blind, controlled phase I study. Thirty subjects received either TG and DM dual SLIT (n= 20) or placebo (n = 10). Immune parameters were evaluated for differentiation of desensitized subjects from control subjects.Subjects treated with dual SLIT had decreased rhinoconjunctivitis scores (P < .001) and medication use scores (P < .001) and reduced responses to TG and DM allergen based on results of skin prick tests or nasal disk challenges (P < .01 and P < .001, respectively) compared with placebo-treated control subjects. An increase in TG- and DM-specific IgG(4) levels, reduced allergen-specific IgE levels, and subsequent basophil activation were observed in the active treatment group. Dual SLIT promoted allergen-specific suppressive CD4(+)CD25(high)CD127(low)CD45RO(+) forkhead box protein 3 (Foxp3)(+) memory regulatory T cells with reduced DNA methylation of CpG sites within the Foxp3 locus.The results of this pilot study suggest that dual SLIT could be an effective means to treat subjects with sensitivities to a variety of allergens and that long-term tolerance might be induced by epigenetic modifications of Foxp3 in memory regulatory T cells.

    View details for DOI 10.1016/j.jaci.2012.04.021

    View details for Web of Science ID 000306644800030

    View details for PubMedID 22677046

    View details for PubMedCentralID PMC4161455

  • Interrater agreement of nasal endoscopy for chronic rhinosinusitis Annual Scientific Meeting of the American-Rhinologic-Society Raithatha, R., Anand, V. K., Mace, J. C., Smith, T. L., Schaberg, M. R., Nyquist, G. G., Hwang, P. H., Senior, B. A., Stankiewicz, J. A., Tabaee, A. WILEY-BLACKWELL. 2012: 144–50

    Abstract

    Nasal endoscopy is a routine, important diagnostic tool in the evaluation of chronic rhinosinusitis (CRS). Although the procedure is ideally "objective," the subjective nature of endoscopy interpretation and lack of standardization are potential limitations. The goal of this study was to examine the interrater agreement of various categories of nasal endoscopy findings in patients undergoing evaluation for CRS.Fourteen patients (28 sides) with CRS underwent clinical evaluation, SNOT-22, sinus computed tomography (CT), and digital video nasal endoscopy. Five academic rhinologists blindly reviewed the endoscopies for structural anatomic issues, inflammatory rhinosinusitis findings, and atypical lesions. Statistical comparison of the endoscopy interpretations was performed using the unweighted Fleiss' kappa statistic (K(f) ).The mean Lund-Mackay CT scan score was 7.8 (standard deviation [SD] 4.9) and the mean SNOT-22 score was 35.8 (SD 22.7). Significant variability was noted among the raters with respect to the various categories of nasal endoscopy findings. The overall levels of interrater agreement for the various categories were as follows: "almost perfect" for atypical lesions (K(f) = 0.912); "substantial" for nasal polyps (K(f) = 0.693); "moderate" for nasal discharge (K(f) = 0.422) and mucosal inflammatory changes of the middle turbinate (K(f) = 0.413); and "fair" for edema of the middle meatus (K(f) = 0.214), obstruction by nasal septum deviation (K(f) = 0.240), and obstruction by the middle turbinate (K(f) = 0.276).Significant variability was noted in the interrater agreement for nasal endoscopy findings in this study, with relatively limited agreement on some of the key findings of the procedure. Additional investigation and standardization of nasal endoscopy interpretation is required to improve the clinical utility of the procedure.

    View details for DOI 10.1002/alr.21009

    View details for Web of Science ID 000308926000011

    View details for PubMedID 22253129

  • Targeted endoscopic salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Ho, A. S., Kaplan, M. J., Fee, W. E., Yao, M., Sunwoo, J. B., Hwang, P. H. 2012; 2 (2): 166-173

    Abstract

    Despite modern radiotherapy and open surgical techniques, treatment of recurrent nasopharyngeal carcinoma (NPC) remains challenging, with substantial morbidity involved. Targeted endoscopic nasopharyngectomy was evaluated as a viable oncologic alternative to open nasopharyngectomy or radiation for recurrent NPC.Thirteen patients who underwent endoscopic nasopharyngectomy for recurrent NPC between August 2005 and August 2010 were retrospectively reviewed. Average age at surgery was 55.7 years, with mean follow-up period 24.2 months. Two-year disease-free survival, 2-year overall survival, margin status, and complication rate were measured.Including resections for subsequent recurrences, 19 endoscopic procedures were performed with curative intent. Mean operating room (OR) time was 278 minutes, mean estimated blood loss was 197 mL, and mean length of hospitalization was 1.0 days. Negative margins were obtained in 78.9% of procedures: positive margins involved the parapharyngeal space, oropharynx, fossa of Rosenmuller, and infratemporal fossa. Stereotactic radiation was given postoperatively for localized positive margins. Four patients required repeat endoscopic nasopharyngectomy for re-recurrence, despite having their margins cleared or controlled with adjuvant treatment. Two-year local disease-free and overall survival rates were 69.2% and 100.0%, respectively. The overall minor complication rate was 52.6%, with no major complications.Targeted endoscopic nasopharyngectomy is beneficial in locally recurrent NPC, with favorable morbidity and complication rates. Endoscopic surveillance and serial imaging together facilitate the early identification of re-recurrences, which often may be treated with additional directed resection. Postoperative stereotactic radiation may serve as an appropriate adjunct modality for disease control at positive margins.

    View details for DOI 10.1002/alr.20111

    View details for PubMedID 22170783

  • Nationwide incidence of major complications in endoscopic sinus surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Ramakrishnan, V. R., Kingdom, T. T., Nayak, J. V., Hwang, P. H., Orlandi, R. R. 2012; 2 (1): 34-39

    Abstract

    Endoscopic sinus surgery (ESS) is one of the most commonly performed procedures in otolaryngology. Major complications are estimated to occur in 1-3% of cases, based on early studies with relatively small patient cohorts in academic institutions. The aim of this study was to update data regarding major complication rates associated with ESS by analyzing a large patient database.Retrospective review of a nationwide database of patients who underwent ESS between 2003 and 2007. Major postoperative complications-cerebrospinal fluid (CSF) leak, orbital injury, and hemorrhage requiring blood transfusion-were identified by searching the database for related International Classification of Diseases, 9th edition (ICD-9) and Current Procedural Terminology (CPT) codes. Complication rates were examined and time to occurrence analyzed. Two-tailed test of proportions, global chi-square test, and logistical regression analysis were used for statistical comparison.A total of 62,823 patients who met rigorous inclusion criteria were included. The overall major complication rate was 1.00% (CSF leak 0.17%; orbital injury 0.07%; hemorrhage requiring transfusion 0.76%). CSF leak was less likely to occur in the pediatric population (p = 0.05), whereas orbital injury was more likely to occur in children (p < 0.001). Examination of the impact of image guidance (IGS) was limited by study design.The incidence of major complications associated with ESS appears to have decreased since early reports over 10 years ago. There may be different complication rates in the pediatric population. Study design limitations did not allow for comprehensive assessment of IGS in the development of these complications. These data help to educate otolaryngologists and patients about complication rates in ESS in a modern context.

    View details for DOI 10.1002/alr.20101

    View details for Web of Science ID 000308925100007

    View details for PubMedID 22311839

  • Interrater reliability of endoscopic parameters following sinus surgery LARYNGOSCOPE Smith, T. L., Hwang, P. H., Murr, A. H., Lavigne, F., Koreck, A. 2012; 122 (1): 230-236

    Abstract

    To determine the interrater reliability of a set of postoperative endoscopic scoring parameters in patients with chronic rhinosinusitis who have undergone endoscopic sinus surgery (ESS).Prospective cohort with retrospective review.One hundred twenty video-endoscopic evaluations in 20 subjects recorded at 14, 30, and 45 days after ESS were scored in real time by the clinical investigators who performed the endoscopies and recorded the videos and retrospectively by an independent panel of four sinus surgeons who were blinded to all information. The scoring parameters included categoric grading for adhesion formation and middle turbinate position and continuous grading (visual analog scale) for degree of inflammation and crusting. Interrater reliability of the panel members was assessed using the Fleiss kappa test, bias index and prevalence index for categoric data, and the Shrout-Fleiss test for continuous data. The level of agreement between the panel and the real-time clinical investigator was also assessed.For categoric variables, strong agreement between raters on the panel was found for both middle turbinate position (kappa=0.499, prevalence index=0.925) and adhesions (kappa=0.364, prevalence index=0.829). For continuous data, good agreement between raters was found for both inflammation (reliability coefficient=0.554) and crusting (reliability coefficient=0.620). Real-time investigator scoring and panel scoring showed strong agreement.These results suggest that the endoscopic scoring parameters assessed (middle turbinate position, adhesions, inflammation, and crusting) have acceptable interexaminer reproducibility and are suitable for evaluating ESS outcomes in the postsurgical period.

    View details for DOI 10.1002/lary.22440

    View details for PubMedID 22095409

  • Xylitol Nasal Irrigation in the Management of Chronic Rhinosinusitis: A Pilot Study LARYNGOSCOPE Weissman, J. D., Fernandez, F., Hwang, P. H. 2011; 121 (11): 2468-2472

    Abstract

    To determine the tolerability of xylitol mixed with water as a nasal irrigant and to evaluate whether xylitol nasal irrigation results in symptomatic improvement of subjects with chronic rhinosinusitis.A prospective, randomized, double-blinded, controlled crossover pilot study.Twenty subjects were instructed to perform sequential 10-day courses of daily xylitol and saline irrigations in a randomized fashion, with a 3-day washout irrigation rest period at the start of each treatment arm. Collected data included patient characteristics, along with Sino-Nasal Outcome Test 20 (SNOT-20) and Visual Analog Scale (VAS) scores reported at the beginning and end of each irrigation course.Fifteen of the 20 subjects (75%) returned their SNOT-20 and VAS data for analysis. There was a significant reduction in SNOT-20 score during the xylitol phase of irrigation (mean drop of 2.43 points) as compared to the saline phase (mean increase of 3.93 points), indicating improved sinonasal symptoms (P = .0437). There was no difference in VAS scores. No patient stopped performing the irrigations owing to intolerance of the xylitol, although its sweet taste was not preferred by three subjects (21%). One patient reported transient stinging with xylitol.Xylitol in water is a well-tolerated agent for sinonasal irrigation. In the short term, xylitol irrigations result in greater improvement of symptoms of chronic rhinosinusitis as compared to saline irrigation.

    View details for DOI 10.1002/lary.22176

    View details for Web of Science ID 000296714800034

    View details for PubMedID 21994147

  • Novel effects of statins in enhancing efficacy of chemotherapy in vitro in nasopharyngeal carcinoma INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Wang, W., Le, W., Cho, D., Hwang, P. H., Upadhyay, D. 2011; 1 (4): 284-289

    Abstract

    Nasopharyngeal cancer (NPC) is a relatively uncommon malignant epithelial cancer seen worldwide. The treatment of NPC has evolved toward combined modality treatment with radiation therapy and chemotherapy. However, chemotherapeutic agents currently have a secondary role, due to their lack of efficacy as curative agents. Recent identification of a novel property of statin drugs raises a promising hope that concurrent use of statins may enhance the efficacy of single-drug chemotherapy in NPC. However, the effects of statins have not been studied before in NPC. In this in vitro study, we demonstrate a unique property of statins that can enhance the efficacy of cisplatin in NPC.Primary human NPC cells (CCL-30) were treated with statins and cisplatin concurrently, and the effects on cell proliferation, apoptosis, and cell colony formation were examined.Statins caused significant decrease in cell proliferation and viability in NPC. Statins also induced loss of cell attachment, change in cellular morphology, decrease in colony forming units, and loss of sphere formation in soft gel agar, which are the important properties of tumorigenicity in NPC. Furthermore, we found that the effects of statins occur by a mevalonate (MA)-mediated pathway in these cells.We demonstrate a unique property of statins that can enhance the antitumor effects of cisplatin in NPC. Statins may act as a relatively safe and cost effective chemoadjuvant agent in the treatment of NPC.

    View details for DOI 10.1002/alr.20039

    View details for Web of Science ID 000308922300010

    View details for PubMedID 22287433

  • Inhibition of Inflammatory Mediators: Role of Statins in Airway Inflammation OTOLARYNGOLOGY-HEAD AND NECK SURGERY Wang, W., Le, W., Ahuja, R., Cho, D., Hwang, P. H., Upadhyay, D. 2011; 144 (6): 982-987

    Abstract

    To determine if statins induce anti-inflammatory effects in upper airway inflammation. Mediators of innate and adaptive immunity regulate airway inflammation. Release of these mediators involves enzymatic conversion of polyunsaturated fatty acids into biologically active mediators, which can be blocked by statins. Although upper airway inflammation and chronic sinusitis occur in millions of patients with asthma worldwide, the anti-inflammatory effects of statins in upper airway inflammation have not been previously studied.Laboratory research.Tertiary referral center.Analysis of sinus tissues collected from patients with chronic rhinosinusitis revealed suppression of highly expressed inflammatory mediators in patients who were found to be on statins, suggesting that statins may induce anti-inflammatory effects. Therefore, the authors performed an in vitro study to determine if these anti-inflammatory effects were induced by statins. Cultured primary human airway epithelial cells were exposed to ambient air pollution particulates (PM) to trigger the inflammation, with and without statins, and the expression of inflammatory mediators was analyzed.The authors found that expression of CCL5, CCL11, and IL13RA was suppressed in patients on statins. In vitro exposure to PM enhanced the expression of these mediators, while pretreatment with statins completely blocked these effects. Furthermore, the effects of statins were blocked by inhibition of the statin pathway using isopentenyl-5-pyrophosphate. Statins did not have any significant effect on the viability of normal cells.Statins induce anti-inflammatory effects in human airway epithelial inflammation. Statins may play a role in the treatment and prevention of chronic rhinosinusitis and pulmonary exacerbation of obstructive airway diseases.

    View details for DOI 10.1177/0194599811400367

    View details for Web of Science ID 000293998800030

    View details for PubMedID 21493317

  • Correlation of Asymmetric Facial Growth with Deviated Nasal Septum LARYNGOSCOPE Kim, Y. M., Rha, K., Weissman, J. D., Hwang, P. H., Most, S. P. 2011; 121 (6): 1144-1148

    Abstract

    To evaluate the correlation between growth differences of the face and nasal septal deviation, and to evaluate whether developmental differences of the face have an effect on nontraumatic nasal septal deviation (DNS).Retrospective study.Twenty-five patients with DNS who underwent facial aesthetic surgery and had an ostiomeatal unit-computed tomography (OMU-CT) scan and photos for facial analysis were included in the study. Coronal views of the OMU-CT scan where the nasal septum was most severely deviated were selected and from which five parameters (angle of septal deviation [ASD], angle of nasal floor [ANF], angle of lateral nasal wall [ALW], angle of inferior turbinate [AIT], and width of IT [WIT]) were measured. Preoperative frontal views of the patients were analyzed by comparing the distances between the following points on both sides of the faces: midsagittal plane to Zygion (MSP-Zy), Glabella to Exocanthion (G-Ex), Exocanthion to Cheilion (Ex-Ch), and Zygion to Cheilion (Zy-Ch).The differences between the right and left MSP-Zy, G-Ex, and Ch-Zy distance were significantly associated with the direction of septal deviation. The difference between the right and left AIT and WIT were also significantly associated with the direction of septal deviation. Using bivariate correlation, it was found that the absolute difference between the right and left MSP-Zy, G-Ex, and WIT showed significant correlation with the amount of septal deviation.We demonstrate that there is a strong relationship between deviated nasal septum and facial growth asymmetry.

    View details for DOI 10.1002/lary.21785

    View details for Web of Science ID 000291259900004

    View details for PubMedID 21495046

  • The effectiveness of preemptive sphenopalatine ganglion block on postoperative pain and functional outcomes after functional endoscopic sinus surgery 56th Annual Fall Scientific Meeting of the American-Rhinologic-Society (ARS) Cho, D., Drover, D. R., Nekhendzy, V., Butwick, A. J., Collins, J., Hwang, P. H. WILEY-BLACKWELL. 2011: 212–18

    Abstract

    The sphenopalatine ganglion block (SPGB) with local anesthetic is used to treat facial pain and headache of various etiologies; it has been widely used during functional endoscopic sinus surgery (FESS). The purpose of this study was to investigate whether preemptive SPGB may positively impact postoperative pain and functional outcomes after FESS.A prospective, double-blind, randomized, placebo-controlled study was performed. A total of 60 patients (18-70 years), undergoing general anesthesia for bilateral FESS, were randomly assigned to receive SPGB with either 2 mL 0.25% bupivacaine with epinephrine 1:100,000 (BP, treatment group) or normal saline (NS, control group). SPGB was performed preemptively 10 minutes before the start of surgery. Preoperative and postoperative (day 0, day 7, and day 30) visual analog pain scale, Sino-Nasal Outcome Test (SNOT-20), computed tomography (CT) and endoscopic scores were compared between the 2 groups.A total of 29 patients were enrolled in BP, and 27 were enrolled in NS. Three patients withdrew from the study, and 1 was withdrawn by the investigator due to severe hypertension after induction of anesthesia. There were no differences in patient demographic characteristics between the study groups. On day 7, the mean visual analog pain scales were 1.12 ± 0.3 in NS and 0.48 ± 0.23 in BP (p = 0.053). There were no statistical differences in other outcome measures (SNOT-20, CT and endoscopic scores) between the 2 groups.A limited trend toward reduced postoperative pain after FESS was noted with bupivacaine compared to saline, but statistical significance was not achieved. Preemptive SPGB may offer sinonasal symptomatic benefits for patients undergoing FESS, but larger studies are warranted.

    View details for DOI 10.1002/alr.20040

    View details for PubMedID 22287376

  • Oral corticosteroid therapy in chronic rhinosinusitis without polyposis: a systematic review INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Lal, D., Hwang, P. H. 2011; 1 (2): 136-143

    Abstract

    Recognition of inflammation in the pathophysiology of chronic rhinosinusitis (CRS) has caused corticosteroid therapy in CRS to gain favor. A systematic evaluation of oral steroid use in CRS without nasal polyps (CRSsNP) has not been previously conducted. The objective of the study was to assess evidence on oral steroid therapy in CRSsNP, via a systematic literature review.Ovid and PubMed databases were searched for studies on oral steroid therapy in CRSsNP. Manuscripts were reviewed and graded by evidence-based medicine (EBM) level.A total of 33 studies met inclusion criteria; 30 on CRSsNP and 3 on allergic fungal sinusitis (AFS). CRSsNP studies did not include any randomized controlled trial (RCT) or any clinical study employing systemic corticosteroids alone. They included 20 reviews/expert opinions (Level 5) with differing recommendations, and 4 treatment guidelines (Level 4) with weak recommendations on use. Three studies, 2 retrospective (Level 4) and 1 prospective study (Level 3), used oral steroids in combination with antibiotics and nasal steroids. The multidrug regimen improved symptoms, radiologic findings, short-term relapses, nasal endoscopy, and cytokine pattern expression. An experimental study (Level 5) found oral steroids to reverse sinonasal tissue inflammation. Two studies in animal models (Level 5) found no benefit of adding systemic steroids to antibiotics. Three clinical AFS studies, 1 RCT (Level 1) and 2 prospective (Level 3), found oral steroids to benefit postoperative recurrence, endoscopy or computed tomography (CT).No study has employed systemic corticosteroids alone in treating CRSsNP. Evidence supporting oral steroid therapy in CRSsNP is mostly Level 4 or 5; there is lack of any RCT to support use.

    View details for DOI 10.1002/alr.20024

    View details for Web of Science ID 000308912300011

    View details for PubMedID 22287332

  • Correlations Between Symptoms, Nasal Endoscopy, and In-Office Computed Tomography in Post-Surgical Chronic Rhinosinusitis Patients Conference on Triological-Society/Combined Otolaryngology Spring Meeting/143rd Annual Meeting of the American-Otological-Society Ryan, W. R., Ramachandra, T., Hwang, P. H. WILEY-BLACKWELL. 2011: 674–78

    Abstract

    To determine correlations between symptoms, nasal endoscopy findings, and computed tomography (CT) scan findings in post-surgical chronic rhinosinusitis (CRS) patients.Cross-sectional.A total of 51 CRS patients who had undergone endoscopic sinus surgery (ESS) completed symptom questionnaires, underwent endoscopy, and received an in-office sinus CT scan during one clinic visit. For metrics, we used the Sinonasal Outcomes Test-20 (SNOT-20) questionnaire, visual analog symptom scale (VAS), Lund-Kennedy endoscopy scoring scale, and Lund-MacKay (LM) CT scoring scale. We determined Pearson correlation coefficients, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) between scores for symptoms, endoscopy, and CT.The SNOT-20 score and most VAS symptoms had poor correlation coefficients with both endoscopy and CT scores (0.03-0.24). Nasal drainage of pus, nasal congestion, and impaired sense of smell had moderate correlation coefficients with endoscopy and CT (0.24-0.42). Endoscopy had a strong correlation coefficient with CT (0.76). Drainage, edema, and polyps had strong correlation coefficients with CT (0.80, 0.69, and 0.49, respectively). Endoscopy had a PPV of 92.5% and NPV of 45.5% for detecting an abnormal sinus CT (LM score ≥1).In post-ESS CRS patients, most symptoms do not correlate well with either endoscopy or CT findings. Endoscopy and CT scores correlate well. Abnormal endoscopy findings have the ability to confidently rule in the presence of CT opacification, thus validating the importance of endoscopy in clinical decision making. However, a normal endoscopy cannot assure a normal CT. Thus, symptoms, endoscopy, and CT are complementary in the evaluation of the post-ESS CRS patient.

    View details for DOI 10.1002/lary.21394

    View details for Web of Science ID 000287789400047

    View details for PubMedID 21305550

  • Acid and base secretion in freshly excised nasal tissue from cystic fibrosis patients with Delta F508 mutation Annual Spring Meeting of the American-Rhinologic-Society (ARS) / Combined Meeting of the Society-of-Otolaryngology / COSM Meeting Cho, D., Hwang, P. H., Illek, B., Fischer, H. WILEY-BLACKWELL. 2011: 123–27

    Abstract

    Cystic fibrosis (CF) is caused by a misfunctional CF transmembrane conductance regulator (CFTR) protein, which is believed to contributes to the regulation of the airway surface liquid (ASL) pH. This study investigated acid and base secretion in freshly excised human nasal tissues from CF patients homozygous for the ΔF508 mutation.Human nasal mucosa was collected during sinus surgery and investigated in Ussing chambers. Mucosal equilibrium pH values and rate of acid and base secretion were determined using the pH-stat technique.The equilibrium pH of nasal epithelia from ΔF508 CF patients with chronic rhinosinusitis (CRS) was pH = 7.08 ± 0.09 and was significantly lower compared to nasal epithelia from CRS patients without CF (pH = 7.33 ± 0.06) and normal subjects (pH = 7.34 ± 0.08, n = 6). The rate of base secretion in CF nasal tissues was 11.8 ± 2.4 nmol · min(−1) · cm(−2), which was significantly lower than normal (57.2 ± 9.2 nmol · min(−1) · cm(−2)). The HCO3(−) secretory rate was further increased by forskolin by 16.1% in normal, but not in CF tissues.Our data suggests that CF patients exhibited significantly lower base secretion by the nasal airway epithelium. It is possible that improper regulation of ASL pH in CF may negatively impact the innate host defense system.

    View details for DOI 10.1002/alr.20028

    View details for Web of Science ID 000308912300009

    View details for PubMedID 22034590

    View details for PubMedCentralID PMC3199580

  • Systematic Review of Topical Vasoconstrictors in Endoscopic Sinus Surgery LARYNGOSCOPE Higgins, T. S., Hwang, P. H., Kingdom, T. T., Orlandi, R. R., Stammberger, H., Han, J. K. 2011; 121 (2): 422-432

    Abstract

    The objective of this study is to systematically review the literature and examine the safety for the use of topical vasoconstrictors in endoscopic sinus surgery.Systematic review clinical trials.A systematic literature search was performed in MEDLINE, EMBASE, The Cochrane Library, and National Guideline Clearinghouse, and references in the selected articles.The search criteria captured 42 manuscripts with relevant titles. A systematic review on the topical use of phenylephrine was found; however, no other systematic review, meta-analyses, or clinical guidelines were identified. Six randomized clinical trials or comparative studies, as well as multiple case reports and review articles were also identified. The literature supports the safety of oxymetazoline and epinephrine when used judiciously in carefully selected patients undergoing endoscopic sinonasal surgery; however, topical phenylephrine is not recommended because of its risk profile.In sinus or nasal surgery, topical vasoconstrictors should be used in a manner that minimizes the risk of cardiovascular morbidity.

    View details for DOI 10.1002/lary.21286

    View details for Web of Science ID 000287006400035

    View details for PubMedID 21271600

  • Safety and efficacy of a novel bioabsorbable, steroid-eluting sinus stent INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Murr, A. H., Smith, T. L., Hwang, P. H., Bhattacharyya, N., Lanier, B. J., Stambaugh, J. W., Mugglin, A. S. 2011; 1 (1): 23-32

    Abstract

    Inflammation/polyp recurrence, adhesions, and middle turbinate lateralization are causes of suboptimal outcomes following sinus surgery and lead to increased rates of revision. A bioabsorbable, drug-eluting stent was evaluated for its ability to preserve sinus patency by providing controlled steroid delivery to the sinus mucosa. The study objective was to assess safety and efficacy of a steroid-eluting sinus stent when used following functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis (CRS).Prospective, multicenter, randomized, double-blind clinical trial, enrolling 43 patients in 2 groups. One group (n = 38) used an intrapatient control design comparing drug-eluting to non-drug-eluting stents. The other group (n = 5) received bilateral drug-eluting stents to assess systemic safety. Endoscopic follow-up was performed for 60 days. Efficacy endpoints included assessment of inflammation, polyp formation, adhesions, and middle turbinate position.Stents were successfully deployed in all 86 sinuses. Compared to the control stent, the drug-eluting stent provided statistically significant reduction in inflammation at days 21 to 45 (p < 0.003), frequency of polyp formation (p = 0.0391), and frequency of significant adhesion (p = 0.0313). Reduced frequency of middle turbinate lateralization was also apparent though not statistically significant. No device-related adverse events occurred. Eluted steroid was unquantifiable systemically and there was no evidence of adrenal cortical suppression.This study demonstrates the safety and efficacy of a novel bioabsorbable, steroid-eluting stent for use in CRS patients. The steroid-eluting stent is effective in improving wound healing by preserving sinus patency, reducing inflammation, and minimizing adhesions via controlled local steroid delivery without measurable systemic exposure.

    View details for DOI 10.1002/alr.20020

    View details for Web of Science ID 000308911900005

    View details for PubMedID 22287304

  • ACID AND BASE SECRETION IN FRESHLY EXCISED NASAL TISSUE FROM CYSTIC FIBROSIS PATIENTS WITH Delta F508 MUTATION Cho, D., Illek, B., Hwang, P. H., Fischer, H. WILEY-BLACKWELL. 2011: 241–242
  • Safety of a Preservative-Free Acidified Saline Nasal Spray A Randomized, Double-blind, Placebo-Controlled, Crossover Clinical Trial ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Ryan, W. R., Hwang, P. H. 2010; 136 (11): 1099-1103

    Abstract

    To determine the safety and tolerance of a buffered preservative-free acidified solution as an alternative to standard chemical preservatives to prevent microbial contamination of saline nasal spray.Randomized, double-blind, placebo-controlled, crossover clinical trial.Tertiary academic medical center.Healthy volunteers with no history or signs of sinonasal disease.Twenty volunteers used a buffered preservative-free acidified solution in a saline nasal spray and a benzalkonium chloride-containing saline nasal spray for 1 week each, separated by a 1-week washout period.At study enrollment and after using each nasal spray solution, participants completed a visual analog scale symptom questionnaire and the 20-Item Sino-Nasal Outcome Test and underwent nasal endoscopic examination, which was graded using a modified Lund-Kennedy scoring system. At the end of each test period, the contents of each nasal spray bottle were cultured for microorganism growth.All 20 participants completed the study. Four participants who developed upper respiratory tract illnesses during the study period were excluded from secondary analyses. No differences were observed in specific sinonasal symptoms or nasal endoscopy findings after use of either nasal spray. No nasal spray solutions from either group had any microorganism growth.In a short-term study with a small sample size, a preservative-free acidified solution seems to be safe and well tolerated, while maintaining sterility in a multiple-dose applicator without use of chemical preservatives.

    View details for Web of Science ID 000284231000009

    View details for PubMedID 21079163

  • Migration of regulatory T cells toward airway epithelial cells is impaired in chronic rhinosinusitis with nasal polyposis CLINICAL IMMUNOLOGY Kim, Y. M., Munoz, A., Hwang, P. H., Nadeau, K. C. 2010; 137 (1): 111-121

    Abstract

    The pathogenesis of chronic rhinosinusitis with nasal polyposis (CRSwNP) is still unclear. To evaluate the role of regulatory T cells (Treg) in the pathogenesis of nasal polyposis, we tested migration potential of Treg purified from subjects with CRSwNP, CRS without NP and controls. The nasal tissue expressions of FOXP3 were analyzed by means of RT-PCR and double immunohistochemistry. Chemotaxis assays were used to evaluate the migration potential of Treg onto bronchial epithelial cells and primary nasal epithelial cells, and toward chemokines. FOXP3(+)CD3(+) cells frequency and FOXP3 transcript expression in nasal tissue, and migration potentials of Treg toward airway epithelial cells and CCL1 were significantly lower in CRSwNP compared with other groups (P<0.05). These results indicate that migration potential of Treg is decreased in CRSwNP subjects, and this may be one of the reasons why tissue infiltration of Treg was decreased as seen in the immunohistochemistry of nasal polyps from CRSwNP subjects.

    View details for DOI 10.1016/j.clim.2010.05.013

    View details for Web of Science ID 000282204900013

    View details for PubMedID 20598643

  • Characteristics of Chloride Transport in Nasal Mucosa From Patients With Primary Ciliary Dyskinesia LARYNGOSCOPE Cho, D., Hwang, P. H., Illek, B. 2010; 120 (7): 1460-1464

    Abstract

    Primary ciliary dyskinesia (PCD) is an inherited disorder that produces lifelong difficulties with chronic airway inflammation. Little is known about the role of chronic airway inflammation on chloride ion transport properties in PCD. This study assessed the cyclic adenosine monophosphate (cAMP)-regulated chloride (Cl) ion transport properties of freshly excised nasal mucosa from PCD compared with normal and chronic rhinosinusitis (CRS).Electrophysiology study utilizing Ussing type hemi-chamber technique with three different types of nasal tissue (normal, CRS, PCD) obtained from patients during endoscopic surgery at a tertiary referral center.Nasal tissues were examined under short-circuit conditions, and gradient-driven Cl currents were continuously recorded. The cAMP elevating agonist (forskolin) was added to stimulate cystic fibrosis transmembrane conductance regulator-mediated Cl secretion. To prevent misinterpretation of flux measurement, Cl transport inhibitors were used at the end of all experiments. Basal Cl currents (I(Cl)) and changes in I(Cl) to forskolin (DeltaI(Cl)) were compared between normal, CRS, and PCD nasal tissues.Forskolin stimulated Cl currents across all different types of nasal epithelia. The Cl secretory response was effectively blocked by the Cl ion transport inhibitors. I(Cl) were significantly higher in normals (155.0 +/- 9.3 microA/cm(2)) compared to CRS (79.1 +/- 15.0 microA/cm(2)) and PCD (70.9 +/- 20.4 microA/cm(2)) (P = .005). DeltaI(Cl) in CRS (14.8 +/- 2.3 microA/cm(2)) and PCD (12.2 +/- 2.4 microA/cm(2)) were markedly diminished compared to normals (28.3 +/- 4.7 microA/cm(2)) (P = .024).PCD tissues were characterized by impaired I(Cl) and DeltaI(Cl). Both parameters were reduced by 54.3% and 56.9% in PCD when compared to normals.

    View details for DOI 10.1002/lary.20928

    View details for Web of Science ID 000279498500032

    View details for PubMedID 20564725

    View details for PubMedCentralID PMC3196355

  • Outcomes After Middle Turbinate Resection: Revisiting a Controversial Topic LARYNGOSCOPE Soler, Z. M., Hwang, P. H., Mace, J., Smith, T. L. 2010; 120 (4): 832-837

    Abstract

    To evaluate differences in endoscopy exam, olfactory function, and quality-of-life (QOL) status after endoscopic sinus surgery (ESS) for patients with and without bilateral middle turbinate (BMT) resection.Open, prospective, multi-institutional cohort.Subjects completing enrollment interviews, computed tomography (CT), and endoscopy exam were asked to provide pre- and postoperative responses to the Smell Identification Test (SIT), Rhinosinusitis Disability Index (RSDI), Chronic Sinusitis Survey (CSS), and the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Bivariate and multivariate analyses were performed at the .05 alpha level.Forty-seven subjects with BMT resection were compared to 195 subjects without BMT resection with a mean follow-up of 17.4 months postoperatively. Patients with BMT resection were more likely to have asthma (P = .001), aspirin intolerance (P = .022), nasal polyposis (P = .025), and prior sinus surgery (P = .002). Patients with BMT resection had significantly higher baseline disease burden measured by endoscopy, CT, and SIT scores (P < .001). No significant differences in improvement were found in RSDI, CSS, or SF-36 scores between patients with BMT resection and those with BMT preservation (P > .05). Patients undergoing BMT resection were more likely to show improvements in mean endoscopy (-4.5 +/- 5.2 vs. -1.9 +/- 4.3; P = .005) and olfaction (5.3 +/- 10.8 vs. 1.3 +/- 7.6, P = .045) compared to those with BMT preservation.This investigation found no difference in QOL outcomes in patients with BMT preservation vs. resection. Patients undergoing BMT resection did, however, show greater improvements in endoscopy and SIT scores, which persisted after controlling for confounding factors.

    View details for DOI 10.1002/lary.20812

    View details for PubMedID 20232413

  • Nicotine induces resistance to chemotherapy in nasal epithelial cancer AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Shen, T., Le, W., Yee, A., Kamdar, O., Hwang, P. H., Upadhyay, D. 2010; 24 (2): E73-E77

    Abstract

    Epidemiological and clinical data implicate that in patients with cancer, continued smoking causes progression of cancer growth and resistance to therapy. The carcinogens possess the ability to block apoptosis, an important mechanism in the development of tumors and resistance to chemotherapy. We previously showed that nicotine enhances growth and proliferation in lung cancer. However, the effects of nicotine, a tobacco carcinogen that inhibits apoptosis, have not been studied before in nasal epithelial carcinoma (NC). In this study, we sought to determine the effects of nicotine on chemotherapy-induced apoptosis in human NC.Primary human NC cells were grown per protocol, treated with combination chemotherapy, and the apoptosis was assessed by TUNEL (terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling) and DNA fragmentation assays. The regulation of mitogen-activated protein kinase (MAPK) and protein kinase B (AKT) signal transduction pathway was examined by real time quantitative polymerized chain reaction, and immunofluorescent staining assays.Combination chemotherapy with cisplatin (35 microM) plus etoposide (20 microM) caused a significant increase in NC apoptosis compared with single agent alone, and nicotine, in part, inhibited chemotherapy-induced apoptosis in NC. Furthermore, nicotine induced activation of AKT and MAPK pathways, while inhibition of MAPK using U0126 and AKT by phosphatidylinositol 3-kinase inhibitor, LY294002, in part, blocked the antiapoptotic effects of nicotine against cisplatin and etoposide-induced apoptosis in NC.Nicotine inhibits chemotherapy-induced apoptosis in NC via the AKT and MAPK-mediated signaling pathways. We speculate that nicotine may play a role in oncogenesis and resistance to cancer therapy in NC.

    View details for DOI 10.2500/ajra.2010.24.3456

    View details for Web of Science ID 000292634800004

    View details for PubMedID 20338106

  • Determinants of outcomes of sinus surgery: A multi-institutional prospective cohort study 113th Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery-Foundation-and-OTO-EXPO Smith, T. L., Litvack, J. R., Hwang, P. H., Loehr, T. A., Mace, J. C., Fong, K. J., James, K. E. SAGE PUBLICATIONS LTD. 2010: 55–63

    Abstract

    1) To measure the proportion of patients with chronic rhinosinusitis (CRS) who experience clinically significant improvement after endoscopic sinus surgery (ESS) in a prospective, multi-institutional fashion. 2) To identify preoperative characteristics that predict clinically significant improvement in quality of life (QOL) after ESS.Prospective, multi-institutional cohort study.Academic tertiary care centers.A total of 302 patients with CRS from three centers were enrolled between July 2004 and December 2008 and followed for an average of 17.4 months postoperatively. Preoperative patient characteristics, CT scan, endoscopy score, and pre- and postoperative quality of life (QOL) data were collected. Univariate and multivariate analyses were performed.Patients improved an average of 15.8 percent (18.9 points) on the Rhinosinusitis Disability Index and 21.2 percent (21.2 points) on the Chronic Sinusitis Survey (both P < 0.001). Patients significantly improved on all eight Medical Outcomes Study Short Form-36 (SF-36) subscales (all P < 0.001). Among patients with poor baseline QOL, 71.7 percent of patients experienced clinically significant improvement on the RSDI and 76.1 percent on the CSS. Patients undergoing primary surgery were 2.1 times more likely to improve on the RSDI (95% confidence interval [CI], 1.2, 3.4; P = 0.006) and 1.8 times more likely to improve on the CSS (95% CI, 1.1, 3.1; P = 0.020) compared with patients undergoing revision surgery.In this prospective, multi-institutional study, most patients experienced clinically significant improvement across multiple QOL outcomes after ESS. Specific patient characteristics provided prognostic value with regard to outcomes.

    View details for DOI 10.1016/j.otohns.2009.10.009

    View details for PubMedID 20096224

  • Mechanistic Studies of Tolerance in sublingual innmunotherapy (SLIT) patients with Dermatophagoides farinae and Timothy grass allergy 10th Annual Meeting of the Federation-of-Clinical-Immunology-Societies Reshamwala, N., Swamy, R., Berquist, S., Nguyen, T., Hoyte, E., Vissamsetti, S., Sivagnanasundaram, A., Saper, V., Hwang, P., Moss, R., Nadeau, K. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2010: S65–S65
  • Controlled steroid delivery via bioabsorbable stent: Safety and performance in a rabbit model Spring Meeting of the American-Rhinologic-Society/Rhinology World Conference 2009 Li, P. F., Downie, D., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2009: 591–96

    Abstract

    Middle turbinate lateralization, adhesions, and inflammation are causes of suboptimal sinus patency following surgery. A bioabsorbable drug-eluting stent has been developed to maintain sinus patency while providing controlled steroid delivery to the sinus mucosa. The aim of this study was to characterize the in vivo drug delivery efficacy and tolerance of this stent in a rabbit model.Bioabsorbable stents coated with mometasone furoate were placed bilaterally in the maxillary sinuses of 31 rabbits via dorsal maxillary sinusotomy. Animals were sacrificed between 5 days and 18 weeks postoperatively. Efficacy was assessed by measuring tissue concentrations of steroid in maxillary sinus and nasal mucosa and by measurement of plasma steroid concentrations. Tolerance was assessed by histological evaluation of the sinus mucosa at different time points.Therapeutic mucosal drug concentrations were attained in a time-dependent fashion (range 175-28,189 ng/g). Plasma drug concentrations were generally near or below the lower limit of quantification (15 pg/mL). Histopathological examination of the mucosa showed no differences in the reaction to steroid-coated stents versus nondrug-coated control stents, with inflammation, epithelial ulceration, and bony reaction ranging from none to mild at all time points. Microscopic fungal hyphae were noted in a small proportion of both treatment and control sinuses, without evidence of associated adverse tissue reaction.In a rabbit model, mometasone-coated bioabsorbable stents are able to provide local steroid delivery with negligible systemic absorption. Corticosteroid-eluting stents may prove useful following endoscopic sinus surgery in maintaining sinus patency and reducing inflammation.

    View details for DOI 10.2500/ajra.2009.23.3391

    View details for Web of Science ID 000272677900009

    View details for PubMedID 19958608

  • Integration of patient-specific paranasal sinus computed tomographic data into a virtual surgical environment 54th Annual Fall Meeting of the American-Rhinologic-Society Parikh, S. S., Chan, S., Agrawal, S. K., Hwang, P. H., Salisbury, C. M., Rafii, B. Y., Varma, G., Salisbury, K. J., Blevins, N. H. OCEAN SIDE PUBLICATIONS INC. 2009: 442–47

    Abstract

    The advent of both high-resolution computed tomographic (CT) imaging and minimally invasive endoscopic techniques has led to revolutionary advances in sinus surgery. However, the rhinologist is left to make the conceptual jump between static cross-sectional images and the anatomy encountered intraoperatively. A three-dimensional (3D) visuo-haptic representation of the patient's anatomy may allow for enhanced preoperative planning and rehearsal, with the goal of improving outcomes, decreasing complications, and enhancing technical skills.We developed a novel method of automatically constructing 3D visuo-haptic models of patients' anatomy from preoperative CT scans for placement in a virtual surgical environment (VSE). State-of-the-art techniques were used to create a high-fidelity representation of salient bone and soft tissue anatomy and to enable manipulation of the virtual patient in a surgically meaningful manner. A modified haptic interface device drives a virtual endoscope that mimics the surgical configuration.The creation and manipulation of sinus anatomy from CT data appeared to provide a relevant means of exploring patient-specific anatomy. Unlike more traditional methods of interacting with multiplanar imaging data, our VSE provides the potential for a more intuitive experience that can replicate the views and access expected at surgery. The inclusion of tactile (haptic) feedback provides an additional dimension of realism.The incorporation of patient-specific clinical CT data into a virtual surgical environment holds the potential to offer the surgeon a novel means to prepare for rhinologic procedures and offer training to residents. An automated pathway for segmentation, reconstruction, and an intuitive interface for manipulation may enable rehearsal of planned procedures.

    View details for DOI 10.2500/ajra.2009.23.3335

    View details for Web of Science ID 000268797300016

    View details for PubMedID 19671264

  • A 51-Year-Old Woman With Acute Onset of Facial Pressure, Rhinorrhea, and Tooth Pain Review of Acute Rhinosinusitis JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hwang, P. H. 2009; 301 (17): 1798-1807

    Abstract

    Acute rhinosinusitis is a common ailment accounting for millions of office visits annually, including that of Mrs D, a 51-year-old woman presenting with 5 days of upper respiratory illness and facial pain. Her case is used to review the diagnosis and treatment of acute rhinosinusitis. Acute viral rhinosinusitis can be difficult to distinguish from acute bacterial rhinosinusitis, especially during the first 10 days of symptoms. Evidence-based clinical practice guidelines developed to guide diagnosis and treatment of acute viral and bacterial rhinosinusitis recommend that the diagnosis of acute rhinosinusitis be based on the presence of "cardinal symptoms" of purulent rhinorrhea and either facial pressure or nasal obstruction of less than 4 weeks' duration. Antibiotic treatment generally can be withheld during the first 10 days of symptoms for mild to moderate cases, given the likelihood of acute viral rhinosinusitis or of spontaneously resolving acute bacterial rhinosinusitis. After 10 days, the likelihood of acute bacterial rhinosinusitis increases, and initiation of antibiotic therapy is supported by practice guidelines. Complications of sinusitis, though rare, can be serious and require early recognition and treatment.

    View details for Web of Science ID 000265742500029

    View details for PubMedID 19336696

  • Effect of L-ascorbate on chloride transport in freshly excised sinonasal epithelia 54th Annual Fall Meeting of the American-Rhinologic-Society Cho, D., Hwang, P. H., Illek, B. OCEAN SIDE PUBLICATIONS INC. 2009: 294–99

    Abstract

    Chronic rhinosinusitis (CRS) occurs at high frequency in patients with cystic fibrosis, suggesting that the cystic fibrosis transmembrane conductance regulator (CFTR) chloride (Cl) ion channel might be involved in the development of chronic sinusitis in the general population. CFTR Cl ion transport controls the hydration of mucosal surfaces and promotes effective mucociliary clearance. Altered ion transport and, hence, disrupted mucociliary function, could play a role in the pathogenesis of sinus disease. L-ascorbate is a metabolically active component of the nasal and tracheobronchial airway lining fluids and appears to serve as an important biological effector of CFTR-mediated chloride secretion. The purpose of this study was to determine the effects of L-ascorbate on Cl ion transport in freshly excised sinonasal epithelia from normal controls and patients with CRS.Four different types of sinonasal tissue (normal sinus mucosa, sinus mucosa from CRS, normal nasal mucosa, nasal mucosa from CRS) were obtained during endoscopic sinus surgery and mounted on sliders with open areas of 0.03-0.71 cm2 between Ussing hemichambers. Short-circuit current (Isc) was continuously recorded, and a serosa-to-mucosa-directed Cl gradient was applied to increase the electrochemical driving force.L-ascorbate (500 microM) stimulated Cl currents (DeltaI(Cl), microA/cm2) across sinonasal epithelia from normal and CRS patients. The Cl secretory response to L-ascorbate was effectively blocked by the Cl ion transport inhibitors glibenclamide and bumetanide. A maximal dose of L-ascorbate (at 1 mM) stimulated 53-70% of Cl currents elicited by the cAMP agonist forskolin. CRS sinonasal tissue was characterized by impaired Cl secretory responses to L-ascorbate that were reduced by 33% in sinus epithelial tissue and by 70% in nasal epithelial tissue when compared with normal subjects. In nasal epithelial tissue from normal subjects, Cl secretion was approximately twofold increased when compared with sinus epithelial tissue. In contrast, nasal versus sinus epithelial tissue from CRS patients showed no differences.Topical administration of L-ascorbate to freshly excised sinus and nasal mucosa enhances chloride secretion. Given that decreased CFTR-mediated Cl secretion may contribute to the development of CRS, L-ascorbate may offer potential as a therapeutic agent for the improvement of mucociliary clearance.

    View details for DOI 10.2500/ajra.2009.23.3316

    View details for Web of Science ID 000266387300011

    View details for PubMedID 19490804

    View details for PubMedCentralID PMC3196350

  • Pathology Quiz Case 1 Glomangiopericytoma (sinonasal-type hemangiopericytoma [HPC]) ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Worden, B., Getz, A., Luo, R., Hwang, P. H. 2009; 135 (5): 520-?

    View details for Web of Science ID 000266207600018

    View details for PubMedID 19451477

  • Endoscopic approach to the infratemporal fossa for treatment of invasive fungal sinusitis AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Goyal, P., Leung, M., Hwang, P. H. 2009; 23 (1): 100-104

    Abstract

    Invasive fungal sinusitis is a progressive disease that can often extend beyond the nasal cavities and paranasal sinuses into surrounding soft tissue and bone. Aggressive antifungal therapy and surgical debridement are the mainstays of management. The pterygopalatine fossa and infratemporal fossa are two regions that are commonly involved in patients with invasive fungal sinusitis. When fungal disease extends to the infratemporal fossa, surgical debridement can be challenging. Traditionally, open approaches have been used for the management of disease in these areas. Advances in endoscopic skull base surgery may allow for less invasive approaches for the management of disease in the infratemporal fossa. This article describes a transnasal endoscopic approach to the infratemporal fossa for debridement of invasive fungal sinusitis.Patients with invasive fungal sinusitis extending into the infratemporal fossa were treated with endoscopic debridement. Records of these patients were reviewed.Endoscopic debridement was performed in four patients with infratemporal fossa extension of invasive fungal sinusitis. Responsible organisms included Aspergillus, Mucor, and Candida. Adequate access and excellent visualization of the infratemporal fossa were obtained in all patients. The endoscopic anatomy and surgical technique are presented.Endoscopic approaches have been used to manage a variety of disease processes that extend beyond the confines of the paranasal sinuses. Invasive fungal sinusitis disease with extension into the infratemporal fossa can be safely debrided via a transnasal endoscopic technique. The approach provides excellent visualization with low morbidity.

    View details for DOI 10.2500/ajra.2009.23.3270

    View details for Web of Science ID 000264995900020

    View details for PubMedID 19379622

  • Pathology Quiz Case Cholesterol granuloma (CG) of the left maxillary sinus ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Parikh, S., Mattoch, I. W., Kong, C., Hwang, P. H. 2008; 134 (11): 1233-1234

    View details for PubMedID 19015458

  • Results of endoscopic maxillary mega-antrostomy in recalcitrant maxillary sinusitis Spring Meeting of the American-Rhinologic-Society/Combined Otolaryngology Spring Meeting Cho, D., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2008: 658–62

    Abstract

    In patients with chronically diseased maxillary sinuses, poor mucociliary clearance may result from long-standing inflammation or scarring from previous surgery. This subset of patients often has persistent sinus disease despite medical therapy and adequate antrostomy. Endoscopic maxillary mega-antrostomy (EMMA) is a mucosal sparing technique that facilitates mucus clearance and sinus irrigation in terminally dysfunctional maxillary sinuses. EMMA involves extending the antrostomy through the posterior half of the inferior turbinate down to the floor of the nose, creating a significantly enlarged antrostomy. This study describes our results of EMMA in recalcitrant maxillary sinusitis.A retrospective review was performed of patients who underwent EMMA for recalcitrant maxillary sinusitis between July 2005 and September 2007. We studied diagnoses, comorbid factors, clinical efficacy, revision rate, and complications.Twenty-eight patients (average age, 48 years) underwent 42 EMMAs for recalcitrant maxillary sinusitis. Average follow-up was 11 months. All patients had previous maxillary sinus surgery (mean = 2.3). Relevant comorbid factors included prior Caldwell-Luc or maxillofacial surgery (16/42), cystic fibrosis (11/42), asthma (11/42), and IgG deficiency (3/42). The most common symptoms reported were facial pain/pressure and purulent rhinorrhea. At the time of the most recent postoperative examination, 74% of patients reported complete resolution of symptoms while 26% reported partial symptomatic improvement. There were no complications and the revision rate was 0%.Maxillary sinuses that appear to be terminally diseased may be rehabilitated surgically without the need for surgical stripping. EMMA is an effective and safe treatment option for the management of recalcitrant maxillary sinus disease.

    View details for DOI 10.2500/ajr.2008.22.3248

    View details for Web of Science ID 000262205600019

    View details for PubMedID 19178809

  • The effects of retinoic acid on ciliary function of regenerated sinus mucosa AMERICAN JOURNAL OF RHINOLOGY Erickson, V. R., Antunes, M., Chen, B., Cohen, N. A., Hwang, P. H. 2008; 22 (3): 334-336

    Abstract

    Retinoic acid (RA) has been shown to enhance ciliary ultrastructure in regenerated sinus mucosa compared with controls. However, the functional status of the regenerated cilia has not been studied. Our objective was to evaluate the ciliary beat frequency (CBF) of regenerated sinus mucosa treated with topical RA in a rabbit model.Twelve rabbits underwent bilateral surgical stripping of the maxillary sinuses, followed by treatment with RA gel in the right side and an inert gel control in the left side. The rabbits were then killed at either 2 or 4 weeks, and CBF analysis of the regenerated mucosa was performed. Three unoperated rabbits were used to establish normative CBF data.Functional cilia were recovered from 11/12 RA-treated sinuses and 12/12 gel control sinuses. At 2 weeks postoperatively, the RA-treated sinuses showed an average CBF of 19.78 Hz, which was statistically comparable with the normal unoperated controls (p < 0.26). The inert gel-treated mucosa showed a CBF of 29.24 Hz, which was significantly elevated compared with normals (p < 0.05). At 4 weeks, ciliary activity persisted, but both RA-treated sinuses and gel controls showed elevated CBF compared with normals (p < 0.03).Topical RA placed in a demucosalized maxillary sinus yields functional cilia. RA appears to have a normalizing effect on CBF early in the mucosal wound healing process compared with control. This effect appears to be mitigated in later stages of wound healing. RA may be beneficial in enhancing morphological and functional aspects of regenerating cilia.

    View details for DOI 10.2500/ajr.2008.22.3176

    View details for Web of Science ID 000256132300022

    View details for PubMedID 18588770

  • Effects of sinus surgery on lung transplantation outcomes in cystic fibrosis AMERICAN JOURNAL OF RHINOLOGY Leung, M., Rachakonda, L., Weill, D., Hwang, P. H. 2008; 22 (2): 192-196

    Abstract

    In cystic fibrosis (CF) patients who are candidates for lung transplant, pretransplant sinus surgery has been advocated to avoid bacterial seeding of the transplanted lungs. This study reviews the 17-year experience of pretransplant sinus surgery among CF patients at a major transplant center.Retrospective chart review was performed in all CF patients who underwent heart-lung or lung transplantation at Stanford Medical Center between 1988 and 2005. Postoperative culture data from bronchoalveolar lavage (BAL) and sinus aspirates were evaluated, in addition to survival data.Eighty-seven CF transplant recipients underwent pretransplant sinus surgery; 87% (n=59/68) of patients showed recolonization of the lung grafts with Pseudomonas on BAL cultures. The median postoperative time to recolonization was 19 days. Bacterial floras cultured from sinuses were similar in type and prevalence as the floras cultured from BAL. When compared with published series of comparable cohorts in which pretransplant sinus surgery was not performed, there was no statistically significant difference in the prevalence of Pseudomonas recolonization. Times to recolonization also were similar. Survival rates in our cohort were similar to national survival rates for CF lung transplant recipients.Despite pretransplant sinus surgery, recolonization of lung grafts occurs commonly and rapidly with a spectrum of flora that mimics the sinus flora. Survival rates of CF patients who undergo prophylactic sinus surgery are similar to those from centers where prophylactic sinus surgery is not performed routinely. Pretransplant sinus surgery does not appear to prevent lung graft recolonization and is not associated with overall survival benefit.

    View details for Web of Science ID 000254801300019

    View details for PubMedID 18416979

  • Balloon catheter technology in sinus surgery AMERICAN JOURNAL OF RHINOLOGY Hwang, P. H. 2008; 22 (2): 105-105

    View details for Web of Science ID 000254801300001

    View details for PubMedID 18416962

  • Endoscopic septoplasty CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Getz, A. E., Hwang, P. H. 2008; 16 (1): 26-31

    Abstract

    Successful septoplasty involves accurate assessment of septal pathology and sound technique to avoid persistent symptoms and new complications. This review highlights endoscopic septoplasty techniques and instrumentation, as well as the indications for and advantages of endoscopic septoplasty as compared with traditional headlight septoplasty.Isolated lesions such as septal spurs and contact points may be better addressed with limited endoscopic techniques. Powered instrumentation has been utilized with reported success. Operative time and outcomes of endoscopic septoplasty are at least commensurate with, and at times superior to, traditional techniques.Endoscopic technology greatly enhances visualization during septoplasty. Discrete septal pathologies such as isolated deflection, spurs, perforations, and contact points can be addressed in a directed fashion. These advantages can be especially important in revision cases. Endoscopic technique in conjunction with video imaging is valuable for the education of residents and staff.

    View details for Web of Science ID 000270375100007

    View details for PubMedID 18197018

  • Radiographic assessment of the sinuses in patients treated for nasopharyngeal carcinoma AMERICAN JOURNAL OF RHINOLOGY Raviv, J., Downing, L., Le, Q., Hwang, P. 2008; 22 (1): 64-67

    Abstract

    Patients undergoing therapy for nasopharyngeal carcinoma (NPC) often experience dysfunction of the sinonasal mucosa as a side effect of radiotherapy and chemotherapy. Sinonasal mucosal changes may vary throughout the treatment and posttreatment periods, but little objective data exist characterizing such changes. We evaluated serial radiologic changes of the paranasal sinus mucosa in patients with NPC undergoing treatment.Medical and radiographic records were reviewed for all patients treated for NPC between 2004 and 2006 at Stanford University Medical Center. Pretreatment computed tomography (CT) images served as the baseline images for comparison, and posttreatment CT and magnetic resonance imaging (MRI) images were categorized temporally into 3-month intervals, up to 25 months after initiation of treatment. Images were scored in a blinded fashion using the Lund-Mackay (LM) staging system.Thirty-five patients received treatment for NPC during the study period, of whom 27 had adequate data for analysis and inclusion in the study. The mean pretreatment LM score was 1.41, and a statistically significant increase in LM score was observed at 3, 6, 9, 12, 15, and 18, 22, and 28 months. There was continued progression of radiologic sinus opacification over the first 30 months after treatment.The treatment of NPC with radiotherapy and chemotherapy is associated with radiologic evidence of sinus mucosal thickening. The extent of mucosal thickening can be expected to progress after treatment for up to 30 months. Patients undergoing treatment for NPC should be monitored carefully throughout the posttreatment period for clinical manifestations of dysfunctional sinonasal mucosa.

    View details for DOI 10.2500/ajr.2007.21.3091

    View details for Web of Science ID 000253232100012

    View details for PubMedID 17958946

  • Wegener's granulomatosis: current trends in diagnosis and management. Current opinion in otolaryngology & head and neck surgery Erickson, V. R., Hwang, P. H. 2007; 15 (3): 170-176

    Abstract

    To provide an update on diagnostic methods and treatment options for Wegener's granulomatosis and to review common head and neck manifestations of the disease.Recent advances have been made in the systemic treatment of Wegener's granulomatosis, including the introduction of investigational immunosuppressive agents such as etanercept, leflunomide and deoxyspergualin. Surgical options remain indicated in selected complications of Wegener's granulomatosis such as saddle nose deformity and subglottic stenosis.Wegener's granulomatosis is an idiopathic, systemic vasculitis characterized by the formation of necrotizing granulomas of the respiratory tract in addition to focal or proliferative glomerulonephritis. Diagnosis is made by a combination of physical examination, laboratory studies and tissue biopsy. Head and neck manifestations are abundant and varied; common sites of involvement include the middle ear, nose and sinuses and subglottis. The mainstay of treatment remains systemic therapy using a combination of glucocorticoids and immunosuppressants. The otolaryngologist plays a key role in the diagnosis and treatment of head and neck complications of the disease. A surgical role exists for the management of nasal and sinus disease as well as laryngeal and tracheal disease.

    View details for PubMedID 17483685

  • Rehabilitation of surgically traumatized paranasal sinus mucosa using retinoic acid 52nd Annual Meeting of the American-Rhinologic-Society Leung, M., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2007: 271–75

    Abstract

    Paranasal sinus mucosa that regenerates after surgical stripping is characterized by sparse, dysmorphic cilia. Although such dysfunctional mucosal changes are thought to be irreversible, the potential rehabilitation of deciliated mucosa by topical therapies has not been explored. This study evaluated the effect of topical retinoic acid (RA) in rehabilitating deciliated sinus mucosa that has regenerated after surgical stripping.Twelve New Zealand rabbits underwent bilateral maxillary sinus mucosal stripping and were allowed to remucosalize for 10 days. In the first treatment arm (n = 6), 0.01% RA was applied to the regenerated mucosa of the left maxillary sinus and an aqueous control was placed contralaterally. In the second treatment arm, the regenerated mucosa was surgically restripped bilaterally before applying RA and control. After 14 additional days, mucosa was harvested and examined by scanning electron microscopy for ciliary density, orientation, and morphology.In the first treatment arm, no significant differences in ciliary density, orientation, or morphology were noted between RA-treated sinuses and controls. In the second arm, RA-treated sinuses showed improved ciliary density, morphology, and orientation compared with controls.RA does not appear to significantly enhance ciliogenesis when applied after mucosal regeneration has occurred. However, if deciliated mucosa is restripped and allowed to regenerate in the presence of RA, ciliary ultrastructural features may be enhanced. RA may have therapeutic value in rehabilitating deciliated sinus mucosa when applied before mucociliary differentiation of regenerating mucosa.

    View details for DOI 10.2500/ajr.2007.21.3035

    View details for Web of Science ID 000247026000003

    View details for PubMedID 17621807

  • Infraorbital nerve surgical decompression for chronic infraorbital nerve hyperesthesia OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY Bailey, K., Ng, J. D., Hwang, P. H., Saulny, S. M., Holck, D. E., Rubin, P. A. 2007; 23 (1): 49-51

    Abstract

    To present three cases of chronic infraorbital nerve hyperesthesia relieved by surgical decompression of the infraorbital nerve.Retrospective chart review.We identified three cases of chronic hyperesthesia of the infraorbital nerve. Two cases were related to previous blunt orbital trauma, whereas the third was associated with a long-standing anophthalmic socket with numerous previous surgeries. In each case, patients had dramatic relief of infraorbital nerve hyperesthesia and pain after surgical decompression of the infraorbital nerve.Surgical decompression of the infraorbital nerve can provide significant symptomatic improvement in patients with chronic infraorbital nerve hyperesthesia secondary to nerve compression.

    View details for DOI 10.1097/IOP.0b013e31802dd3fc

    View details for PubMedID 17237691

  • Image-guided frontal trephination: A minimally invasive approach for hard-to-reach frontal sinus disease OTOLARYNGOLOGY-HEAD AND NECK SURGERY Zacharek, M. A., Fong, K. J., Hwang, P. H. 2006; 135 (4): 518-522

    Abstract

    Peripherally located frontal sinus pathology may be unreachable with standard endoscopic techniques. Patients with superiorly or laterally based lesions often undergo osteoplastic flap with or without obliteration. Image-guided frontal trephination (IGFT) can localize pathology and provide excellent exposure. We present 13 patients in whom this technique was applied.Medical records of 13 patients undergoing IGFT were retrospectively reviewed.The patients' mean age was 49.2 years, (range 14-79); follow-up time was 29.9 months (range 12-39). Indications for IGFT were superiorly or laterally based mucoceles (3), fibrous dysplasia or osteoma (3), type 4 frontal cells (3), and frontal recess stenosis or ossification (4). In five patients, IGFT was combined with endoscopic transethmoid frontal sinusotomy; eight patients were treated through a trephination approach, and three patients underwent trephination with unilateral frontal sinus obliteration. One patient required revision; all others remain symptom free.IGFT offers an attractive alternative to osteoplastic flap.

    View details for DOI 10.1016/j.otohns.2006.05.033

    View details for Web of Science ID 000241210500007

    View details for PubMedID 17011410

  • The utility of concurrent rhinoplasty and sinus surgery - A 2-team approach ARCHIVES OF FACIAL PLASTIC SURGERY Marcus, B., Patel, Z., Busquets, J., Hwang, P. H., Cook, T. A. 2006; 8 (4): 260-262

    Abstract

    To evaluate the safety and efficiency of and patient satisfaction with a 2-team approach for combined rhinoplasty and sinus surgery.We conducted a retrospective medical chart analysis of consecutive patients with sinus disease and functional nasal obstruction. Forty-four patients (29 women and 15 men; age range, 22-75 years) had severe nasal obstruction with chronic sinusitis and were found to have indications for this procedure. All patients were followed up for a minimum of 6 months after surgery. Patients completed a standardized questionnaire at the time of medical chart review, and 36 patients completed a telephone interview.All 44 patients underwent rhinoplasty with an endoscopic sinus procedure. Twenty-seven procedures (61%) were endonasal, whereas 17 (39%) were open rhinoplasty. Patients with internal nasal valve collapse underwent 28 butterfly grafts, 6 spreader grafts, and 8 batten grafts. The endoscopic sinus procedures consisted of maxillary antrostomy (30/44 [68%]) and ethmoidectomy (28/44 [63%]). Overall, 20 (65%) of 31 patients reported a postsurgical nasal airway that was significantly improved. Most sinus symptoms were resolved postoperatively, with 25 (71%) of 35 patients describing their improvement as significant. Thirty-two (92%) of 36 patients stated that they would recommend the concurrent procedure.Patients presenting with nasal obstruction and chronic sinusitis tolerated combined rhinoplasty and sinus procedures without added morbidity.

    View details for Web of Science ID 000239078900006

    View details for PubMedID 16847172

  • Retinoic acid improves ciliogenesis after surgery of the maxillary sinus in rabbits LARYNGOSCOPE Hwang, P. H., Chan, J. M. 2006; 116 (7): 1080-1085

    Abstract

    Retinoids have been shown to be important cofactors in regulating the differentiation and proliferation of ciliated epithelial cells of the respiratory tract. In particular, retinoic acid has been shown to enhance the regeneration of paranasal sinus mucosa. The objective of this study is to use scanning electron microscopy techniques to evaluate the effect of topical retinoic acid on mucosal wound healing in a rabbit model of maxillary sinus surgery. It is hypothesized that the application of topical retinoic acid will enhance ciliogenesis and improve the morphology of regenerated cilia compared with controls.Prospective multi-arm controlled animal trial.Eighteen New Zealand white rabbits underwent surgical opening of the maxillary sinuses through a midline incision. The rabbits were divided among four experimental groups: 1) mucosal stripping alone (stripped control), 2) stripping followed by topical application of an inert aqueous gel, 3) stripping followed by application of 0.01% retinoic acid in aqueous gel, and 4) no mucosal stripping and no topical treatment (nonstripped control). After 14 days, the medial wall of the maxillary sinus was harvested and examined by scanning electron microscopy at x2,000 and x5,000 magnification. The micrographs were then rated by a blinded review panel for ciliary density, orientation, and morphology.Mean scores for ciliary density, orientation, and morphology were all significantly higher for the retinoic acid treatment group compared with both the inert aqueous gel treatment group and the stripped control group (P=.004-.03 for all comparisons, Student's t test). Mean scores for the retinoic acid treatment group were numerically lower than the nonstripped control group but did not approach statistical significance for any parameter (P=.23-.31).In a rabbit model of maxillary sinus surgery, topically delivered retinoic acid enhances ciliogenesis. Qualitative assessment of ciliary density, orientation, and morphology shows improved healing in retinoic acid treated sinuses compared with both untreated control sinuses and aqueous gel treated sinuses.

    View details for DOI 10.1097/01.mlg.0000224352.50256.99

    View details for Web of Science ID 000238873800003

    View details for PubMedID 16826040

  • Perioperative care for advanced rhinology procedures OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Orlandi, R. R., Hwang, P. H. 2006; 39 (3): 463-?

    Abstract

    Successful outcomes in rhinologic surgery require careful endoscopic interventions, not only in the operating room, but also in the perioperative setting. In particular, meticulous postoperative care is essential to successful outcomes. This article reviews aspects of wound healing and perioperative care that can optimize surgical patency and clinical outcome.

    View details for DOI 10.1016/j.otc.2006.01.006

    View details for Web of Science ID 000238507600005

    View details for PubMedID 16757225

  • The utility of bipolar electrocautery in hereditary hemorrhagic telangiectasia 109th Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery-Foundation Ghaheri, B. A., Fong, K. J., Hwang, P. H. MOSBY-ELSEVIER. 2006: 1006–9

    Abstract

    The surgical treatment of epistaxis associated with hereditary hemorrhagic telangiectasia (HHT) is varied. Laser therapy is often inadequate for larger complex lesions. This study sought to determine if bipolar cautery can be effectively and safely used in treating HHT-associated epistaxis.Records from all patients with HHT treated surgically over 8 years were reviewed retrospectively. Outcomes or complications were noted in the clinic on follow-up evaluation.Twenty-seven patients with HHT who underwent surgical treatment of epistaxis were evaluated; 18 were treated with bipolar cautery. Forty-two separate bipolar treatments were performed. No new septal perforations or synechiae were noted. Twenty-two of 42 treatments were coupled with ancillary laser treatments. The bipolar was also used as the sole technique in 20 procedures.Bipolar electrocautery is a safe and effective tool for the intraoperative control of HHT-related epistaxis.Bipolar electrocautery may be used as an adjunct to laser techniques or as a stand-alone technique.C-4.

    View details for DOI 10.1016/j.otohns.2005.12.019

    View details for PubMedID 16730547

  • Intranasal deposition of nebulized saline: A radionuclide distribution study 50th Annual Meeting of the American-Rhinologic-Society Hwang, P. H., Woo, R. J., Fong, K. J. OCEAN SIDE PUBLICATIONS INC. 2006: 255–61

    Abstract

    Despite the popularity of various nasal sprays and nebulizers, there are limited data regarding the anatomic distribution of particles generated by these devices. This pilot study sought to characterize distribution patterns of nebulized and sprayed saline particles in normal subjects and postsurgical sinus patients.Fifteen subjects were studied in three trials: metered-dose nasal spray bottle versus vortex-propelled nebulizer in normal subjects, passive-diffusion nebulizer versus vortex nebulizer in normal subjects, and passive nebulizer versus vortex nebulizer in postsurgical sinus patients. Radiolabeled saline was administered, and nose, lungs, and stomach were imaged. Images were scored by four blinded reviewers for degree of penetration at nine anatomic subsites.Compared with spray bottle, the vortex nebulizer showed more focal intranasal distribution with reduced nasopharyngeal, pharyngeal, and gastric penetration in normal subjects. Three of five subjects showed probable frontal sinus penetration by vortex nebulizer, but no other sinus penetration was noted. No patients showed sinus penetration with the spray bottle. In a separate trial against the passive nebulizer, the vortex nebulizer again showed a greater tendency for sinus penetration in normal subjects, with three of five showing some degree of sphenoid penetration and one of five showing slight maxillary penetration. In contrast, no sinus penetration was observed with the passive nebulizer. In the postsurgical patient cohort, minimal sinus penetration was noted with either the vortex nebulizer or the passive nebulizer. Despite surgically patent sinuses, only one of five subjects showed any type of sinus penetration.The nebulizer and nasal spray devices tested in general showed limited penetration of the sinuses in both normal and postoperative patients. The device showing greatest promise for sinus penetration in normal patients was the vortex nebulizer, with an overall penetration rate in normal patients of 30% in the frontal, 30% in the sphenoid, and 10% in the maxillary. Understanding delivery patterns of topical therapies may be important in evaluating the efficacy of various topical treatment modalities.

    View details for DOI 10.2500/ajr.2006.20.2861

    View details for Web of Science ID 000238925900004

    View details for PubMedID 16871925

  • Endoscopic resection of sinonasal inverted papilloma: A meta-analysis OTOLARYNGOLOGY-HEAD AND NECK SURGERY Busquets, J. M., Hwang, P. H. 2006; 134 (3): 476-482

    Abstract

    Endoscopic resection has become an increasingly popular method of treating sinonasal inverted papillomas. The literature on endoscopic approaches to inverted papilloma consists primarily of relatively small case series (grade C evidence). This study aims to systematically review and integrate the available literature to objectively compare success rates of endoscopic versus nonendoscopic tumor resection techniques.A systematic review of the literature on resection of inverted papillomas.Comprehensive review of the English-language literature on resection of inverted papillomas was performed. The reports were subdivided into endoscopic approaches versus nonendoscopic approaches, applying strict inclusion and exclusion criteria. Our institution's experience with endoscopic treatment of inverted papilloma was also included. Studies from the era of endoscopic sinus surgery (1992-2004) formed a "contemporary" cohort and were compared with a "historical" cohort developed from the literature between 1970 and 1995.Thirty-two studies were included in the contemporary cohort, comprising 714 patients treated endoscopically and 346 patients treated nonendoscopically. Thirteen studies in the historical cohort yielded 692 patients treated nonendoscopically. There was a significantly lower recurrence rate in the contemporary cohort compared with the historical cohort (15% v 20%, P = 0.02). Within the contemporary cohort, endoscopically treated patients had significantly lower recurrences than nonendoscopically treated patients (12% v 20%, P < 0.01). Notably, the recurrence rate for nonendoscopically treated patients in the contemporary cohort was equivalent to that of the nonendoscopic patients in the historical cohort (20% v 19%, P = 0.78).A systematic review of the literature supports endoscopic resection as a favorable treatment option for most cases of sinonasal inverted papilloma. EBM rating: B-3a.

    View details for DOI 10.1016/j.otohns.2005.11.038

    View details for PubMedID 16500448

  • Surgical revision of the post-Caldwell-Luc maxillary sinus Annual Meeting of the American-Rhinologic-Society Han, J. K., Smith, T. L., Loehrl, T. A., Fong, K. J., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2005: 478–82

    Abstract

    Endoscopic sinus surgeons are commonly faced with the management of patients with persistent maxillary sinusitis despite previous Caldwell-Luc surgery. Given the potential for altered mucociliary clearance in the post-Caldwell-Luc maxillary sinus, the optimal approach for surgical revision has not been well characterized. The objective of this study was to review our experience in endoscopic versus repeat Caldwell-Luc approaches in patients who have failed Caldwell-Luc surgery for chronic maxillary sinusitis.Retrospective chart review was performed on patients who had a history of a Caldwell-Luc procedure and who then underwent a surgical revision for persistent maxillary sinusitis at the Oregon Health and Science University and Medical College of Wisconsin between 1983 and 2002.Sixty-eight patients were identified, with a total of 156 revision procedures performed on 103 maxillary sinuses. Fifty-three percent of the sinuses underwent endoscopic maxillary antrostomy as the first surgical revision, while 47% underwent a revision Caldwell-Luc procedure. Sixty-seven percent of the sinuses in the revision endoscopic group had clinical resolution with a single surgical revision, and 60% of the sinuses in the revision Caldwell-Luc group had clinical improvement with one surgical revision (p = 0.46). The endoscopic group averaged 1.3+/-0.5 revision procedures per sinus to achieve clinical resolution, and the revision Caldwell-Luc group averaged 1.7+/-1.0 revision procedures per sinus (p = 0.3). Mean follow-up was 25 months.Endoscopic revision of the maxillary sinus yields comparable outcomes to repeat Caldwell-Luc procedure in patients with a history of previous failed Caldwell-Luc surgery. Endoscopic revision surgery is a viable alternative for surgical rehabilitation of the post-Caldwell-Luc maxillary sinus.

    View details for PubMedID 16270602

  • Surgical revision of the failed obliterated frontal sinus 49th Annual Fall Meeting of the American-Rhinologic-Society Hwang, P. H., Han, J. K., Bilstrom, E. J., Kingdom, T. T., Fong, K. J. OCEAN SIDE PUBLICATIONS INC. 2005: 425–29

    Abstract

    Surgical revision of failed frontal sinus obliteration, traditionally, has been limited to repeat obliteration. However, endoscopic techniques may be successful in selected cases. We review our experience in surgical revision of failed frontal obliteration and propose a management algorithm.Retrospective chart review was performed over a 5-year period for patients who presented for surgical revision of a previously obliterated frontal sinus. Indications for surgery, radiological findings, and surgical approach were reviewed.Nineteen patients were identified, presenting an average of 9.7 years from the initial obliteration. Eighty-four percent (n = 16) were approached endoscopically and 16% (n = 3) were approached by revision obliteration. The mean follow-up was 25 months. In the endoscopic group, patients had either mucoceles in the inferomedial aspect of the frontal sinus or incomplete obliteration with persistent disease in the pneumatized frontal remnant. Eighty-one percent (13/16) were managed successfully with a single endoscopic procedure. Nineteen percent (3/16) had persistent disease requiring either a subsequent obliteration or Riedel ablation because of infected fat graft or frontal osteomyelitis. All patients who were managed successfully endoscopically remained free of disease with patent frontal sinusotomies throughout the follow-up period. The endoscopic failures required one to two additional external procedures to achieve disease resolution. In the revision obliteration group, all patients had mucoceles in either the lateral or the superior frontal sinus. All three patients had resolution of disease after a single procedure and remained free of disease throughout the follow-up period.Selected patients undergoing revision of frontal obliteration may benefit from endoscopic approaches. If disease is localized in the frontal recess or inferomedial frontal sinus, endoscopic management may be successful in the majority of patients. Superior or lateral frontal disease appears to be best approached externally. Patients undergoing endoscopic salvage should be counseled about the possible need for revision obliteration if disease persists.

    View details for Web of Science ID 000232986700001

    View details for PubMedID 16270593

  • Sagittal and coronal dimensions of the ethmoid roof: A radioanatomic study AMERICAN JOURNAL OF RHINOLOGY Zacharek, M. A., Han, J. K., Allen, R., Weissman, J. L., Hwang, P. H. 2005; 19 (4): 348-352

    Abstract

    Understanding the anatomy of the ethmoid roof is critical to safe surgical outcomes. Normative data regarding the height and slope of this region have been somewhat limited, derived primarily from cadaveric coronal computed tomography (CT) studies. With triplanar imaging programs, precise multidimensional measurements of the ethmoid roof are now possible. We present a radioanatomic study to characterize normative sagittal and coronal dimensions of the ethmoid roof.Bilateral measurements were taken in 100 consecutive sinus CT scans using ThinClient 3D software. In the sagittal plane, the height of the ethmoid roof was measured in quadrants at five equidistant points between the frontal beak and sphenoid face, referencing the nasal floor. In the coronal plane, the ethmoid roof was measured at three points at the level of the anterior ethmoid artery and at two points at the junction of the posterior ethmoid and sphenoid sinuses.When examined sagittally, the right side showed significantly lower skull base heights in the anterior ethmoid compared with the left side (59.0 mm versus 59.8 mm, p = 0.017; 53.7 mm versus 54.5 mm, p = 0.0004). Coronal measurements of the anterior ethmoid roof showed similar significant differences. The anterior ethmoid roof had greater asymmetries of height compared with the posterior ethmoid roof, which was fairly constant.This study provides numerical correlates to accepted concepts regarding the shape and slope of the ethmoid roof. Differences in height of the skull base between right and left sides, especially in the anterior ethmoid sinus, may be an important surgical consideration. The posterior ethmoid roof appears to be relatively constant and should serve as a reliable surgical landmark.

    View details for Web of Science ID 000231680000005

    View details for PubMedID 16171167

  • Surgical rhinology: recent advances and future directions OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Hwang, P. H. 2004; 37 (2): 489-?

    Abstract

    The discipline of rhinology is poised on the cusp of explosive growth in its cumulative body of knowledge. Advances in surgical technique, applied technology, and basic science over the past 2 decades have yielded significant benefits to both practitioner and patient. The future holds great promise for continued technical innovation, acquisition of new knowledge,and advances in the science of rhinology.

    View details for PubMedID 15064076

  • The office management of recalcitrant rhinosinusitis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Zacharek, M. A., Hwang, P. H., Fong, K. J. 2004; 37 (2): 365-?

    Abstract

    The patient referred to the otolaryngologist for the treatment of CRS has received many therapies for the condition. Newer therapies available focus on the anti-inflammatory therapies and local application of antimicrobial and antifungal agents to the sinus cavities. Much clinical work remains to be done to prove the efficacy of currently available treatments. The recent advances in the understanding of allergic and immune mechanisms may allow eventual intervention at the level of cytokines and other immunomodulators of inflammation. The complex cascade of interleukins and proinflammatory agents in CRS patients may some day allow "silver bullet" therapies in the properly selected patient. Until then, a systematic approach to the evaluation of these patients and management with the currently available treatment modalities may help relieve the symptoms in patients with CRS.

    View details for DOI 10.1016/S0030-6665(03)00170-1

    View details for PubMedID 15064068

  • Head and neck manifestations of Wegener's granulomatosis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Gubbels, S. P., Barkhuizen, A., Hwang, P. H. 2003; 36 (4): 685-?

    Abstract

    Wegener's granulomatosis is an idiopathic, granulomatous disease with the potential for multiple head and neck manifestations. The otolarygologist is an essential part of the multidisciplinary team involved in establishing the diagnosis and providing ongoing care for patients with Wegener's granulomatosis. Diagnostic difficulties abound in Wegener's granulomatosis, making repeat biopsies and the use of ANCA imperative. Medical therapy consisting of corticosteroids and immunosuppressive agents is the mainstay of treatment in Wegener's granulomatosis, whereas surgery is reserved for selected head and neck manifestations. With appropriate medical and surgical treatment, many patients living with Wegener's granulomatosis can enjoy a good quality of life.

    View details for DOI 10.1016/S0030-665(03)00023-9

    View details for PubMedID 14567060

  • Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery Meeting of the Western-Section of the Triological-Society Shiley, S. G., Limonadi, F., Delashaw, J. B., Barnwell, S. L., Andersen, P. E., Hwang, P. H., Wax, M. K. JOHN WILEY & SONS INC. 2003: 1283–88

    Abstract

    The incidence of cerebrospinal fluid (CSF) leak following trans-sphenoidal surgery ranges from 0.5% to 15.0%. Factors predicting which patients are likely to develop postoperative leaks and optimal management of these patients are poorly defined. The objective was to determine 1) the incidence of CSF leak following trans-sphenoidal surgery; 2) demographic or intraoperative factors associated with postoperative leaks; 3) techniques and efficacy of postoperative leak management at Oregon Health and Science University, (Portland, OR).Retrospective chart review.Two hundred thirty-five trans-sphenoidal surgeries were performed on 216 patients between 1994 and 2001. Follow-up data were available for 217 operations (92.3%) performed on 202 patients (93.5%).Postoperative CSF leaks occurred in 6.0% (13 of 217) of patients. Leaks were more common in the setting of revision surgery versus primary surgery (14.6% vs. 4.0%, P =.0096), nonadenomatous disease versus pituitary adenoma (15.8% vs. 5.1%, P =.059), or if an intraoperative leak occurred (12.7% vs. 2.7%, P =.004). However, on multivariate analysis, only the presence of intraoperative leak (P =.008) and nonadenomatous disease (P =.047) were found to be independently associated with postoperative CSF leak. Size of adenoma was not associated with occurrence of postoperative CSF leak (6.4% for microadenoma vs. 4.2% for macroadenoma) on both univariate and multivariate analysis. There were 13 postoperative CSF leaks: 2 resolved with lumbar drainage and 11 required operative management (three required multiple procedures). Of the three patients who required multiple operations, two had hospital courses complicated by meningitis and postinfectious hydrocephalus and ultimately required ventriculoperitoneal shunts. Endoscopic re-exploration was successful in 87.5% (7 of 8) of cases.Cerebrospinal fluid leaks following trans-sphenoidal surgery occurred in 6.0% of cases. Nonadenomatous disease and presence of an intraoperative leak were independent predictors of a postoperative leak. Endoscopic re-exploration combined with packing was an effective technique in managing uncomplicated postoperative leaks. In the setting of meningitis and postinfectious hydrocephalus, more invasive techniques such as ventriculoperitoneal shunt may be necessary.

    View details for PubMedID 12897546

  • Effects of topically applied biomaterials on paranasal sinus mucosal healing AMERICAN JOURNAL OF RHINOLOGY Maccabee, M. S., Trune, D. R., Hwang, P. H. 2003; 17 (4): 203-207

    Abstract

    Recently, nasal packing made of absorbable biomaterial has become increasingly popular. Although absorbable packs are effective for hemostasis, their impact on healing mucosa is unknown. Some have felt that a biocompatible sinus dressing actually may enhance healing, particularly in areas where the mucosa has been stripped. The aim of this study was to determine the effect of topical MeroGel and FloSeal on paranasal sinus mucosal healing in a rabbit model.Bilateral maxillary sinuses of 12 New Zealand white rabbits were surgically opened and stripped of mucosa. The left maxillary sinus of six rabbits had sterile saline-soaked MeroGel placed in the antrum, and the other six rabbits received FloSeal. The right maxillary sinuses of all 12 animals were stripped and otherwise untreated to serve as stripped controls. The animals were killed at 2 weeks and specimens were examined by light microscopy.MeroGel-treated mucosa showed extensive fibrosis of the basal lamina and lamina propria, complete loss of surface epithelium, and loss of the mucociliary blanket. There was minimal resorption of the MeroGel, and MeroGel fibers were frankly incorporated into the regenerated epithelium, associated with an exuberant lymphocytic infiltrate. FloSeal-treated mucosa showed similar fibrosis of the basal lamina and lamina propria with loss of the mucociliary blanket, although to a lesser degree than the MeroGel- treated group. FloSeal showed similar incorporation into the healed mucosa with lymphocytosis. Controls showed expected submucosal gland reduction, lamina propria fibrosis, and loss of cilia, but the lamina propria fibrosis seen in the MeroGel and FloSeal groups was markedly more prominent.In a rabbit model, MeroGel and FloSeal appear to increase reactionary fibrosis of healing mucosa. These agents also appear to be incompletely resorbed and grossly incorporated into healing tissue. Mucosal healing may be impaired by the application of these agents.

    View details for PubMedID 12962189

  • Paranasal sinus mucosal regeneration: The effect of topical retinoic acid AMERICAN JOURNAL OF RHINOLOGY Maccabee, M. S., Trune, D. R., Hwang, P. H. 2003; 17 (3): 133-137

    Abstract

    Paranasal sinus mucosa may suffer morphological and functional alterations as a result of surgical trauma. Mucosal stripping typically yields regenerated mucosa characterized by fibrosis, inflammatory infiltrate, and dysmorphic or absent cilia. The aim of this study was to determine the effect of topical retinoic acid (vitamin A) on regeneration of paranasal sinus mucosa.Both maxillary sinuses of 12 New Zealand white rabbits were surgically opened and stripped of mucosa. Six rabbits received 0.01% topical retinoic acid gel treatment to the stripped left maxillary sinus (low concentration group). The remaining six rabbits received 0.025% topical retinoic acid gel to the stripped left maxillary sinus (high concentration group). The stripped right maxillary sinus of all 12 rabbits served as the operated, untreated control to reflect the normal healing process. Six other animals served as unoperated controls. The sinus mucosa was examined by light microscopy after 14 days.Untreated regenerated mucosa showed expected changes of submucosal gland loss, basal lamina and lamina propria fibrosis, cellular atypia, and loss of cilia. Topical retinoic acid treatment appeared to result in better mucosal regeneration marked by less cellular atypia and fibrosis. Although the regenerated mucosa was still grossly abnormal, the degree of ciliary loss and cellular derangement was reduced. The lower-concentration retinoic acid group had more favorable morphology than the higher-concentration retinoic acid group, and both were improved when compared with no treatment.In a rabbit model, topical vitamin A in the form of retinoic acid gel appears to enhance regeneration of ciliated paranasal sinus mucosa. This preliminary study suggests that topical retinoids may have applicability in promoting sinus wound healing.

    View details for PubMedID 12862400

  • Radiologic correlates of symptom-based diagnostic criteria for chronic rhinosinusitis OTOLARYNGOLOGY-HEAD AND NECK SURGERY Hwang, P. H., Irwin, S. B., Griest, S. E., Caro, J. E., Nesbit, G. M. 2003; 128 (4): 489-496

    Abstract

    In 1997, the Task Force on Rhinosinusitis (TFR) set forth symptom-based diagnostic guidelines for chronic rhinosinusitis (CRS). In the present study, we examined radiologic correlates of the TFR diagnostic criteria for rhinosinusitis.One hundred twenty-five consecutive patients undergoing computed tomography (CT) scans of the sinuses were studied at Oregon Health and Science University. Patients were evaluated prospectively with a questionnaire based on the TFR criteria, and their CT scans were graded according to the Lund-Mackay scoring system.Of the 125 patients, 115 met the symptom criteria for CRS. However, 40 of 115 had negative scans (Lund-McKay score, 0) despite meeting the diagnostic criteria for rhinosinusitis. Of 115, 75 had positive scans (Lund-McKay score, >1). Of the 10 patients who had negative diagnoses for rhinosinusitis, 9 had a positive CT scan. The Kappa coefficient was -0.103 (+/-95% confidence interval, -0.201 to -0.004), indicating poor agreement between CRS positivity and CT positivity. The sensitivity of TFR criteria for detecting a positive scan was 89%, but the specificity was poor at only 2%.Based on these pilot data, it appears that the specificity and predictive value of the current TFR criteria may not be adequate to serve as a diagnostic standard for rhinosinusitis. Additional validating data may provide guidance for improving the sensitivity and specificity of symptom-based diagnostic instruments for rhinosinusitis.

    View details for DOI 10.1016/mhn.2003.95

    View details for PubMedID 12707650

  • Contemporary use of image-guided systems. Current opinion in otolaryngology & head and neck surgery Han, J. K., Hwang, P. H., Smith, T. L. 2003; 11 (1): 33-36

    Abstract

    Technologic advancements in radiographic imaging and interactive computers have allowed image-guided systems to be developed, which have been used to characterize surgical anatomy with greater accuracy and detail. Early generations of image-guided systems were difficult to use; however, recent modifications have allowed it to become more user friendly and less cumbersome. As a result, the application of image-guided systems has expanded and its use has become more frequent. Two major designs, optical and electromagnetic, have been used. Although most image-guided systems use computed tomography digital images, magnetic resonance image-based image-guided systems serve a unique and useful purpose. Future directions for image-guided surgery include smaller flexible instrumentation and simplified registration. As image-guided systems continue to evolve, they will enable otolaryngologist to broaden the horizon of minimally invasive techniques and operations.

    View details for PubMedID 14515099

  • Outpatient intravenous antibiotics for chronic rhinosinusitis Annual Meeting of the Western-Section of the Triological-Society Gross, N. D., McInnes, R. J., Hwang, P. H. JOHN WILEY & SONS INC. 2002: 1758–61

    Abstract

    Peripherally inserted central catheter (PICC) lines have greatly facilitated the use of intravenous antibiotics in outpatient medical practice. Otolaryngologic applications for home intravenous therapy through PICC lines have not been well characterized to date. The purpose of the study is to describe indications and complications related to outpatient intravenous antibiotic therapy in patients with chronic rhinosinusitis.Retrospective cohort study.Chart review of patients with chronic rhinosinusitis who were treated at an academic rhinology practice with outpatient intravenous antibiotics over a 3-year period. RESULTS Fourteen patients receiving, in all, 16 courses of intravenous antibiotic therapy through PICC line were identified. The average patient age was 51 years (age range, 36-74 y). The primary indication for intravenous antibiotic use was the treatment of resistant pathogens (50%). The most common organisms treated were, and. Other indications included gastrointestinal intolerance of oral antibiotics and extranasal complications of sinusitis. Eighty-eight percent of patients (14 of 16) were able to complete the entire prescribed course of therapy. Three (19%) catheter-related complications occurred, including thrombophlebitis and deep venous thrombosis. All three complications required removal of the PICC line; one of these patients underwent successful reinsertion of a second catheter and completion of treatment.Peripherally inserted central catheter line delivery of home intravenous antibiotics can be a well-tolerated adjunct to surgery in the outpatient treatment of chronic rhinosinusitis. Resistant infections, intolerance to oral antimicrobials, and extranasal complications of sinusitis are indications for PICC line therapy. Catheter-related complications can be significant and must be considered in patient selection.

    View details for PubMedID 12368610

  • Headset-related sensory and motor neuropathies in image-guided sinus surgery ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Hwang, P. H., Maccabee, M., Lindgren, J. A. 2002; 128 (5): 589-591

    Abstract

    Complications related to the use of image-guided systems in sinus surgery are fortunately rare. We report a case series of 6 patients who experienced facial neuropathies (both sensory and motor) related to the use of a headset for electromagnetic-based image-guided surgery. The auriculotemporal nerve was the most common sensory nerve involved, and the buccal branch of the facial nerve was implicated in a case of motor weakness. The cause of the complication appears to be a pressure neuropathy caused by a tight-fitting headset against the external auditory meatus and temporomandibular joint. Additional risk factors for headset-related neuropathy may relate to body habitus, length of surgical procedure, and patient positioning. All patients' neuropathies resolved completely without intervention. Headset-related complications appear to be uncommon but may be an important consideration in counseling patients who are candidates for image-guided sinus surgery.

    View details for PubMedID 12003594

  • Bony abnormalities of the paranasal sinuses in patients with Wegener's granulomatosis Annual Meeting of the American-Rhinologic-Society Yang, C., Talbot, J. M., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2001: 121–25

    Abstract

    Wegener's granulomatosis is a systemic vasculitis that can affect any organ system, but primarily involves the upper and lower respiratory tracts and the kidneys. Chronic sinusitis is a well-known clinical feature of the disease. Mucosal abnormalities of the nose and paranasal sinuses have been well-characterized and range from granulomatous lesions to diffuse mucosal thickening. In contrast, abnormalities of the underlying bone of the paranasal sinuses in this disease have not been well-described, and reports have been limited. To characterize bony abnormalities of the nose and paranasal sinuses in patients with Wegener's granulomatosis, we performed a retrospective review of all patients with Wegener's granulomatosis who underwent a sinus CT scan at our institution between 1989 and 1999. Nine patients were identified. A total of 22 distinct bony abnormalities were identified in 5 patients. Specific bony findings included bony erosion and destruction of the septum and turbinates; erosion of the ethmoid sinuses; neo-osteogenesis of the maxillary, frontal, and sphenoid sinuses; and complete bony obliteration of the maxillary, frontal, and sphenoid sinuses. Although these findings are suggestive of Wegener's granulomatosis, they are not pathognomonic. Bony changes on sinus CT scan may provide radiologic evidence of underlying Wegener's granulomatosis when clinical suspicion is high.

    View details for PubMedID 11345151

  • Medical therapy of acute and chronic frontal rhinosinusitis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Maccabee, M., Hwang, P. H. 2001; 34 (1): 41-?

    Abstract

    Despite innovations in surgical treatment of frontal sinus disease, medical therapy continues to be important. Preoperative, perioperative, and postoperative considerations are discussed. Diagnostic criteria, microbiology, and complications associated with frontal rhinosinusitis are also reviewed.

    View details for PubMedID 11344060

  • The five year experience with endoscopic trans-septal frontal sinusotomy OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Lanza, D. C., McLaughlin, R. B., Hwang, P. H. 2001; 34 (1): 139-?

    Abstract

    Endoscopic trans-septal frontal sinusotomy (TSFS) represents a unique surgical approach to the floor of the frontal sinus. Although the final result can have similarities to the modified Lothrop procedure in that the intersinus septum may be drilled out, endoscopic TSFS represents a novel approach that can be valuable in patients with certain anatomic configurations. Endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist to augment treatment of refractory frontal sinus disease. This procedure is best considered for patients with favorable anatomy who have significant frontal sinus disease and cannot be managed adequately through an endoscopic frontal sinusotomy.

    View details for Web of Science ID 000168611200013

    View details for PubMedID 11344069

  • Applications of in situ hybridization techniques in the diagnosis of chronic sinusitis AMERICAN JOURNAL OF RHINOLOGY Hwang, P. H., Montone, K. T., Gannon, F. H., Senior, B. A., Lanza, D. C., Kennedy, D. W. 1999; 13 (5): 335-338

    Abstract

    The clinical significance of positive bacterial cultures in chronic sinusitis is often difficult to assess. Contaminants from surface colonization of the sinus mucosa may be difficult to distinguish from true intramucosal or bone involvement. Furthermore, tissue Gram stains are frequently unable to demonstrate the presence of bacteria in tissue despite endoscopic evidence of active sinusitis. In situ hybridization (ISH) techniques using bacterial rRNA probes were applied to evaluate the presence of intramucosal and intraosseous bacteria in chronic sinusitis surgical specimens. A total of 22 specimens of chronically inflamed human ethmoid bone were evaluated by ISH and by Gram stain. In three specimens, ISH identified bacterial rRNA within sinus mucosa and mucin. Notably, in these three ISH-positive specimens, Gram stain was negative in two. No specimen showed evidence of bacterial rRNA within bone. These preliminary results suggest that in situ hybridization may be a useful adjunct to current methods of detecting microorganisms within chronically infected sinus tissue.

    View details for PubMedID 10582109

  • Endoscopic trans-septal frontal sinusotomy: The rationale and results of an alternative technique AMERICAN JOURNAL OF RHINOLOGY McLaughlin, R. B., Hwang, P. H., Lanza, D. C. 1999; 13 (4): 279-287

    Abstract

    Endoscopic transseptal frontal sinusotomy (TSFS) represents an alternate approach to surgical treatment of chronic frontal sinus disease that is refractory to traditional modes of medical and surgical therapy. We retrospectively reviewed our experience with endoscopic TSFS from 1995-1997. Twenty-one procedures were performed through a transseptal approach. One patient was excluded for failure to follow-up, for a total of 20 procedures. Patients were followed with serial endoscopic examinations and a telephone questionnaire with a mean follow-up of 12 months (Range 1-24 months) and 16 months (range 5-31), respectively. The primary indication for surgery was frontal recess stenosis after previous endoscopic frontal sinusotomy in 17/20 (85%). Three patients were considered poor candidates for a primary endoscopic frontal sinusotomy. Patency was maintained in all patients during the follow-up period. A diameter of greater than 3 mm was confirmed by passage of a curved suction in 19/20 (95%). Of the 19 patients that were evaluated via a telephone questionnaire, 17 patients (89.5%) reported some degree of improvement in their nasal/sinus symptoms, and 12/18 patients (67%) felt the frequency of medication requirements was less than that before undergoing endoscopic TSFS. We conclude that endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist, to augment treatment of refractory frontal sinus disease. This procedure seems especially suited for revision surgery in those patients with acquired frontal sinus stenosis. In revision operations with distorted anatomical landmarks, localization of the frontal sinus may be improved with the aid of 3-dimensional computer assisted localization systems. Unlike traditional frontal sinus obliteration, endoscopic TSFS does not preclude radiographic assessment postoperatively, and allows for endoscopic evaluation of the frontal sinus in the office setting.

    View details for Web of Science ID 000082368600005

    View details for PubMedID 10485014

  • Endoscopic septoplasty: Indications, technique, and results 101st Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Hwang, P. H., McLaughlin, R. B., Lanza, D. C., Kennedy, D. W. MOSBY-ELSEVIER. 1999: 678–82

    Abstract

    Endoscopic septoplasty is an attractive alternative to traditional "headlight" approaches to septoplasty. The primary advantage of the technique is the ability to reduce morbidity and postoperative swelling in isolated septal deviations by limiting the dissection to the area of the deviation. This ability to markedly reduce the extent of subperichondrial dissection is particularly valuable in patients who have undergone prior septal cartilage resection. Other advantages include improved visualization, particularly in posterior septal deformities; improved surgical transition between septoplasty and sinus surgery; and its use as an effective teaching tool. We present our experience with endoscopic septoplasty in a series of 111 patients. Surgical indications, technique, and complications are discussed.

    View details for PubMedID 10229592

  • Facial nerve dysfunction associated with cystic lesions of the mastoid OTOLARYNGOLOGY-HEAD AND NECK SURGERY Hwang, P. H., Jackler, R. K. 1998; 119 (6): 668-672

    View details for PubMedID 9852546

  • Correction of the twisted nose deformity: A surgical algorithm using the external rhinoplasty approach American-Rhinologic-Society Meeting, Combined Otolaryngological Spring Meeting Hwang, P. H., Maas, C. S. OCEAN SIDE PUBLICATIONS INC. 1998: 213–20

    Abstract

    Successful correction of the twisted nose is challenging due to the complex nature of the underlying anatomic deformity. Although the literature has in general supported endonasal rhinoplasty techniques for the twisted nose, we propose a surgical algorithm using the external rhinoplasty approach. The algorithm offer a stepwise, structured method that is adaptable to individual variations in anatomic deformity. The advantages and relative disadvantages of the external rhinoplasty approach are discussed, and a clinical experience of 30 patients is reviewed. Application of the external rhinoplasty algorithm in correction of the twisted nose can yield consistently satisfactory functional and aesthetic results.

    View details for PubMedID 9653481

  • Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis 100th Annual Meeting of the American-Laryngological-Rhinological-and-Otological-Society Kennedy, D. W., Senior, B. A., Gannon, F. H., Montone, K. T., Hwang, P., Lanza, D. C. JOHN WILEY & SONS INC. 1998: 502–7

    Abstract

    Mucosal changes have been well described in chronic sinusitis, yet little is known about the underlying bone, despite clinical and experimental evidence suggesting that bone may be involved in chronic sinusitis. Techniques of undecalcified bone analysis were used for detailed histologic examination of ethmoid bone in chronic sinusitis compared with controls. Bone synthesis, resorption, and inflammatory cell presence were specifically assessed. Additionally, histomorphometry techniques were used to determine ethmoid bone physiology in individuals undergoing surgery for chronic sinusitis. Overall, individuals undergoing surgery for chronic sinusitis were found to have evidence of marked acceleration in bone physiology with histologic changes including new bone formation, fibrosis, and presence of inflammatory cells. These findings are compared with osteomyelitis in long bone and the jaw. The suggestion that underlying bone may serve as a catalyst for chronic sinusitis is supported and implications for therapy are discussed.

    View details for Web of Science ID 000072939100008

    View details for PubMedID 9546260

  • Lipoid meningitis due to aseptic necrosis of a free fat graft placed during neurotologic surgery LARYNGOSCOPE Hwang, P. H., Jackler, R. K. 1996; 106 (12): 1482-1486

    Abstract

    We present two unusual cases of aseptic postoperative lipoid meningitis resulting from necrosis of a free fat graft placed into a skull base craniotomy defect. Two patients underwent translabyrinthine resection of acoustic neuroma and received abdominal fat grafts to ablate the surgical defect. Both patients presented postoperatively with persistent cerebrospinal fluid (CSF) wound leak and severe headache. Computed tomography demonstrated hydrocephalus and widely dispersed intracranial fat droplets throughout the CSF circulation. Both patients ultimately required CSF diversion for management of persistent communicating hydrocephalus. The clinical and radiographic correlates of lipocephalus and lipoid meningitis are presented, and a review of free fat graft physiology is discussed.

    View details for Web of Science ID A1996VX21200007

    View details for PubMedID 8948607

  • Attitudes, knowledge, and practices of otolaryngologists treating patients infected with HIV Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Hwang, P. H., Tami, T. A., Lee, K. C., Raven, R. B. MOSBY-YEAR BOOK INC. 1995: 733–39

    Abstract

    The AIDS epidemic has become one of the most important public health problems of this century. As the prevalence of HIV infection continues to rise, health care practitioners in all geographic regions can expect greater clinical exposure to patients infected with HIV. We conducted an anonymous survey of all practicing otolaryngologists in Ohio and California to investigate regional differences in attitudes, knowledge, and practices regarding the care of patients infected with HIV. We also examined the data with respect to year of completion of residency training to identify differences in attitudes or practices among otolaryngologists who trained in the era of AIDS (post-1982 graduates) in comparison with their predecessors (pre-1982 graduates). In comparison with Ohio otolaryngologists, California otolaryngologists reported more frequent clinical encounters with HIV-infected patients and displayed significantly better knowledge regarding the otolaryngologic aspects of HIV infection. Californians were more likely to support the right of an HIV-infected physician to maintain an unrestricted practice and would be less likely to disclose their HIV status to their patients and hospital if they were to become infected with HIV. Post-1982 graduates had more frequent encounters with HIV-infected patients than did pre-1982 graduates and demonstrated a better fund of knowledge. Although Californians were more likely than Ohioans to routinely double glove in surgery, the overall double gloving rate was low at 21%. Californians were no more likely than Ohioans to routinely use protective eyewear, water-impervious gowns, or indirect instrument-passing techniques in surgery. No differences were observed in prevalence of protective surgical precautions between pre-1982 and post-1982 graduates.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1995TK81300013

    View details for PubMedID 7501385

  • ENLARGEMENT OF THE COCHLEAR AQUEDUCT - FACT OR FICTION 1992 ANNUAL MEETING OF THE AMERICAN ACADEMY OF OTOLARYNGOLOGY - HEAD AND NECK SURGERY Jackler, R. K., Hwang, P. H. SAGE PUBLICATIONS LTD. 1993: 14–25

    Abstract

    Enlargement of the cochlear aqueduct (CA) is often mentioned in the otologic literature, usually in its purported association with sensory hearing loss, stapes gusher, and transotic cerebrospinal fluid leak. In CT scans of 100 ears, the diameter of the CA medial aperture was found to be highly variable, ranging from 0 to 11 mm, with a mean of 4.5 mm. In contrast, the otic capsule segment was very narrow in every case. It could be visualized in only 56% of cases, none of which exceeded 2 mm in diameter. Several published reports of supposed CA enlargement presented images of a dilated medial aperture that was well within the range of normal variability according to the present study. In a thorough review of the literature on radiology of the CA, we were unable to find a single published image that convincingly demonstrated enlargement of the otic capsule portion. As radiographic CA enlargement has not been convincingly reported to date, it appears to be an exceedingly rare or perhaps even nonexistent malformation. It is important to recognize than even a radiographically normal CA may be hyperpatent. It is theoretically possible for increased fluid flow to result from either deficiencies in intraluminal membrane baffles or subtle canal enlargement beneath the resolution limits of CT scanning. However, as fluid flow through a tube is regulated by its narrowest point, it is extremely improbable that stapes gusher, transotic CSF leak, and vigorous perilymphatic fistula are generated by the CA when CT scans show any portion of it to be very narrow. A substantial body of evidence points to a deficient partition between the internal auditory canal and inner ear as causative in such cases. We propose that the criteria for the diagnosis of CA enlargement on high-resolution CT scan be a diameter exceeding 2 mm throughout its course from the posterior fossa to the vestibule.

    View details for Web of Science ID A1993LP14800004

    View details for PubMedID 8336962

  • Pediatric penetrating keratoplasty. Seminars in ophthalmology Hwang, D. G., Hwang, P. H. 1991; 6 (4): 212-218

    View details for PubMedID 10149522

  • COLLAGEN SHIELD ENHANCEMENT OF TOPICAL DEXAMETHASONE PENETRATION ARCHIVES OF OPHTHALMOLOGY Hwang, D. G., STERN, W. H., Hwang, P. H., MACGOWANSMITH, L. A. 1989; 107 (9): 1375-1380

    Abstract

    Collagen corneal shields were investigated as a vehicle for enhancing the ocular penetration of topical 0.1% dexamethasone alcohol in rabbit eyes. Four protocols were compared: a single dexamethasone drop, hourly drops, a 24-hour collagen shield presoaked in 0.1% dexamethasone, and a presoaked collagen shield followed by hourly drops. Dexamethasone concentrations in the cornea, aqueous, iris, and vitreous were measured by radioassay at six time intervals, and cumulative drug delivery over 6 hours was calculated for each tissue. Treatment with a presoaked collagen shield plus hourly drops resulted in peak and cumulative drug delivery to the cornea, aqueous, iris, and vitreous that was twofold to fourfold higher than delivery achieved with hourly drops alone. A presoaked shield by itself yielded equivalent or superior peak and cumulative drug delivery compared with a regimen of hourly drops. Collagen shields significantly enhance topical dexamethasone penetration and may be useful for maximizing the intraocular delivery of dexamethasone and for decreasing the required frequency of topical dexamethasone administration.

    View details for Web of Science ID A1989AQ16700031

    View details for PubMedID 2783071