Tulio Valdez, MD, MSc

All Publications

• Executive Summary of Clinical Practice Guideline on Immunotherapy for Inhalant Allergy. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Gurgel, R. K., Baroody, F. M., Damask, C. C., Mims, J. W., Ishman, S. L., Baker, D. P., Contrera, K. J., Farid, F. S., Fornadley, J. A., Gardner, D. D., Henry, L. R., Kim, J., Levy, J. M., Reger, C. M., Ritz, H. J., Stachler, R. J., Valdez, T. A., Reyes, J., Dhepyasuwan, N. 2024; 170 (3): 635-667

  Abstract

  Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care.The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.The guideline development group made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The guideline development group made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitization, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The guideline development group offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

  View details for DOI 10.1002/ohn.650

  View details for PubMedID 38408153

• Clinical Practice Guideline: Immunotherapy for Inhalant Allergy. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Gurgel, R. K., Baroody, F. M., Damask, C. C., Mims, J. W., Ishman, S. L., Baker, D. P., Contrera, K. J., Farid, F. S., Fornadley, J. A., Gardner, D. D., Henry, L. R., Kim, J., Levy, J. M., Reger, C. M., Ritz, H. J., Stachler, R. J., Valdez, T. A., Reyes, J., Dhepyasuwan, N. 2024; 170 Suppl 1: S1-S42

  Abstract

  Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care.The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

  View details for DOI 10.1002/ohn.648

  View details for PubMedID 38408152

• Development of Oxadiazolone Activity-Based Probes Targeting FphE for Specific Detection of Staphylococcus aureus Infections. Journal of the American Chemical Society Jo, J., Upadhyay, T., Woods, E. C., Park, K. W., Pedowitz, N. J., Jaworek-Korjakowska, J., Wang, S., Valdez, T. A., Fellner, M., Bogyo, M. 2024

  Abstract

  Staphylococcus aureus (S. aureus) is a major human pathogen that is responsible for a wide range of systemic infections. Since its propensity to form biofilms in vivo poses formidable challenges for both detection and treatment, tools that can be used to specifically image S. aureus biofilms are highly valuable for clinical management. Here, we describe the development of oxadiazolone-based activity-based probes to target the S. aureus-specific serine hydrolase FphE. Because this enzyme lacks homologues in other bacteria, it is an ideal target for selective imaging of S. aureus infections. Using X-ray crystallography, direct cell labeling, and mouse models of infection, we demonstrate that oxadiazolone-based probes enable specific labeling of S. aureus bacteria through the direct covalent modification of the FphE active site serine. These results demonstrate the utility of the oxadizolone electrophile for activity-based probes and validate FphE as a target for the development of imaging contrast agents for the rapid detection of S. aureus infections.

  View details for DOI 10.1021/jacs.3c13974

  View details for PubMedID 38411555

• Label-Free Optical Technologies for Middle-Ear Diseases Bioengineering Zhou, Z., Pandey, R., Valdez, T. A. 2024; 11 (2)

  View details for DOI 10.3390/bioengineering11020104

• Post-tonsillectomy outcomes in children with mucopolysaccharidosis and obstructive sleep apnea. Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale Elwell, Z., Mancuso, D., Wolter, N. E., Propst, E. J., Valdez, T., Scheffler, P. 2023; 52 (1): 87

  Abstract

  To describe the incidence of respiratory complications, postoperative hemorrhage, length of stay, and cost of care in children with mucopolysaccharidosis (MPS) undergoing adenotonsillectomy (AT).Analysis of the 2009, 2012, and 2016 editions of the Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP KID) identified 24,700 children who underwent AT (40 children with MPS). Demographics, respiratory complications, postoperative hemorrhage, length of stay, and total cost were compared across children with and without MPS.Children with MPS had a higher likelihood of being male (P < 0.017). There was a higher rate of respiratory complications in children with MPS compared with children without MPS [6/40 (15%) vs. 586/24,660 (2.4%), P < 0.001], which remained significant after adjusting for sex [adjusted odds ratio 6.88 (95% CI 2.87-16.46)]. There was also a higher risk of postoperative hemorrhage [4/40 (10%) vs. 444/24,660 (1.8%), P < 0.001), with sex-adjusted odds ratio of 5.97 (95% CI 2.12-16.86). Median (IQR) length of stay was increased in children with MPS (3 days, 1-4) compared with children without MPS (1 day, 1-2, P < 0.001). There was an increase in median (IQR) charges for hospital stay in children with MPS compared with their peers [$33,016 ($23,208.50-$72,280.50 vs. $15,383 ($9937-$24,462), P < 0.001].Children with MPS undergoing AT had an increased risk of respiratory complications, postoperative hemorrhage, longer length of stay, and a higher cost of treatment when compared with children without MPS. This information may help inform interventional, perioperative, and postoperative decision making.

  View details for DOI 10.1186/s40463-023-00685-y

  View details for PubMedID 38142272

  View details for PubMedCentralID PMC10748856

• Spatial subsetting enables integrative modeling of oral squamous cell carcinoma multiplex imaging data. iScience Einhaus, J., Gaudilliere, D. K., Hedou, J., Feyaerts, D., Ozawa, M. G., Sato, M., Ganio, E. A., Tsai, A. S., Stelzer, I. A., Bruckman, K. C., Amar, J. N., Sabayev, M., Bonham, T. A., Gillard, J., Diop, M., Cambriel, A., Mihalic, Z. N., Valdez, T., Liu, S. Y., Feirrera, L., Lam, D. K., Sunwoo, J. B., Schürch, C. M., Gaudilliere, B., Han, X. 2023; 26 (12): 108486

  Abstract

  Oral squamous cell carcinoma (OSCC), a prevalent and aggressive neoplasm, poses a significant challenge due to poor prognosis and limited prognostic biomarkers. Leveraging highly multiplexed imaging mass cytometry, we investigated the tumor immune microenvironment (TIME) in OSCC biopsies, characterizing immune cell distribution and signaling activity at the tumor-invasive front. Our spatial subsetting approach standardized cellular populations by tissue zone, improving feature reproducibility and revealing TIME patterns accompanying loss-of-differentiation. Employing a machine-learning pipeline combining reliable feature selection with multivariable modeling, we achieved accurate histological grade classification (AUC = 0.88). Three model features correlated with clinical outcomes in an independent cohort: granulocyte MAPKAPK2 signaling at the tumor front, stromal CD4+ memory T cell size, and the distance of fibroblasts from the tumor border. This study establishes a robust modeling framework for distilling complex imaging data, uncovering sentinel characteristics of the OSCC TIME to facilitate prognostic biomarkers discovery for recurrence risk stratification and immunomodulatory therapy development.

  View details for DOI 10.1016/j.isci.2023.108486

  View details for PubMedID 38125025

  View details for PubMedCentralID PMC10730356

• Development of Oxadiazolone Activity-Based Probes Targeting FphE for Specific Detection of S. aureus Infections. bioRxiv : the preprint server for biology Jo, J., Upadhyay, T., Woods, E. C., Park, K. W., Pedowitz, N. J., Jaworek-Korjakowska, J., Wang, S., Valdez, T. A., Fellner, M., Bogyo, M. 2023

  Abstract

  Staphylococcus aureus is a major human pathogen responsible for a wide range of systemic infections. Since its propensity to form biofilms in vivo poses formidable challenges for both detection and treatment, tools that can be used to specifically image S. aureus biofilms are highly valuable for clinical management. Here we describe the development of oxadiazolonebased activity-based probes to target the S. aureus-specific serine hydrolase FphE. Because this enzyme lacks homologs in other bacteria, it is an ideal target for selective imaging of S. aureus infections. Using X-ray crystallography, direct cell labeling and mouse models of infection we demonstrate that oxadiazolone-based probes enable specific labeling of S. aureus bacteria through the direct covalent modification of the FphE active site serine. These results demonstrate the utility of the oxadizolone electrophile for activity-based probes (ABPs) and validate FphE as a target for development of imaging contrast agents for the rapid detection of S. aureus infections.

  View details for DOI 10.1101/2023.12.11.571116

  View details for PubMedID 38168396

  View details for PubMedCentralID PMC10760020

• Faculty and Leadership Advancement for People of Color in Otolaryngology CURRENT OTORHINOLARYNGOLOGY REPORTS Solis, R. N., Valdez, T. A. 2023

  View details for DOI 10.1007/s40136-023-00490-1

  View details for Web of Science ID 001074183700001

• Cough Sounds in Screening and Diagnostics: A Scoping Review. The Laryngoscope Hegde, S., Sreeram, S., Alter, I. L., Shor, C., Valdez, T. A., Meister, K. D., Rameau, A. 2023

  Abstract

  The aim of the study was to examine applications of cough sounds towards screening tools and diagnostics in the biomedical and engineering literature, with particular focus on disease types, acoustic data collection protocols, data processing and analytics, accuracy, and limitations.PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, IEEE Xplore, Engineering Village, and ACM Digital Library were searched from inception to August 2021.A scoping review was conducted on screening and diagnostic uses of cough sounds in adults, children, and animals, in English peer-reviewed and gray literature of any design.From a total of 438 abstracts screened, 108 articles met inclusion criteria. Human studies were most common (77.8%); the majority focused on adults (57.3%). Single-modality acoustic data collection was most common (71.2%), with few multimodal studies, including plethysmography (15.7%) and clinico-demographic data (7.4%). Data analytics methods were highly variable, with 61.1% using machine learning, the majority of which (78.8%) were published after 2010. Studies commonly focused on cough detection (41.7%) and screening of COVID-19 (11.1%); among pediatric studies, the most common focus was diagnosis of asthma (52.6%).Though the use of cough sounds in diagnostics is not new, academic interest has accelerated in the past decade. Cough sound offers the possibility of an accessible, noninvasive, and low-cost disease biomarker, particularly in the era of rapid development of machine learning capabilities in combination with the ubiquity of cellular technology with high-quality recording capability. However, most cough sound literature hinges on nonstandardized data collection protocols and small, nondiverse, single-modality datasets, with limited external validity. Laryngoscope, 2023.

  View details for DOI 10.1002/lary.31042

  View details for PubMedID 37672667

• Development of a shortwave infrared sinuscope for the detection of cerebrospinal fluid leaks. Journal of biomedical optics Klein, T. W., Yang, S., Tusty, M. A., Nayak, J. V., Chang, M. T., Bruns, O. T., Bischof, T. S., Valdez, T. A. 2023; 28 (9): 094803

  Abstract

  Cerebrospinal fluid (CSF) rhinorrhea (leakage of brain fluid from the nose) can be difficult to identify and currently requires invasive procedures, such as intrathecal fluorescein, which requires a lumbar drain placement. Fluorescein is also known to have rare but significant side effects including seizures and death. As the number of endonasal skull base cases increases, the number of CSF leaks has also increased for which an alternative diagnostic method would be highly advantageous to patients.We aim to develop an instrument to identify CSF leaks based on water absorption in the shortwave infrared (SWIR) without the need of intrathecal contrast agents. This device needed to be adapted to the anatomy of the human nasal cavity while maintaining low weight and ergonomic characteristics of current surgical instruments.Absorption spectra of CSF and artificial CSF were obtained to characterize the absorption peaks that could be targeted with SWIR light. Different illumination systems were tested and refined prior to adapting them into a portable endoscope for testing in 3D-printed models and cadavers for feasibility.We identified CSF to have an identical absorption profile as water. In our testing, a narrowband laser source at 1480 nm proved superior to using a broad 1450 nm LED. Using a SWIR enabling endoscope set up, we tested the ability to detect artificial CSF in a cadaver model.An endoscopic system based on SWIR narrowband imaging can provide an alternative in the future to invasive methods of CSF leak detection.

  View details for DOI 10.1117/1.JBO.28.9.094803

  View details for PubMedID 37188003

  View details for PubMedCentralID PMC10181794

• Canal wall up versus canal wall down mastoidectomy techniques in the pediatric population with cholesteatoma: A systematic review and meta-analysis of comparative studies. International journal of pediatric otorhinolaryngology Solis-Pazmino, P., Siepmann, T., Scheffler, P., Ali, N. E., Lincango-Naranjo, E., Valdez, T. A., Prokop, L. J., Min-Woo Illigens, B., Ponce, O. J., Ahmad, I. N. 2023; 173: 111658

  Abstract

  The optimal surgical management of cholesteatoma remains controversial. Within pediatric otolaryngology, one of the most vital points of contention is the selection of canal wall-up (CWU) versus canal wall-down (CWD) procedures. Pediatric cholesteatoma has high rates of recurrence (16%-54%). In adults, there is evidence that the selection of surgical techniques affects recurrence rates. This has not been shown in children.1. To systematically review the literature on recurrent and residual cholesteatoma after CWU and CWD in children and perform a meta-analysis of the data. 2. To assess the rates of recurrent and residual cholesteatoma between CWU and CWD techniques in pediatric patients. 3. To assess hearing outcomes by evaluating postoperative differences in the air-bone gap (ABG) between CWU and CWD techniques.A systematic search of PubMed, Embase, Scopus, and Cochrane Collaboration was performed from inception to May 1st, 2020, to identify studies that compared CWU and CWD procedures for acquired cholesteatoma in children.Search records were screened in duplicate by four reviewers. Inclusion criteria consisted of comparative randomized clinical trials and observational studies assessing outcomes of CWU and CWD techniques in the pediatric population. Studies involving patients with congenital cholesteatoma were excluded.Four reviewers working independently and in duplicate systematically reviewed and extracted study data. Dichotomous variables were analyzed as risk ratios (RR), while continuous variables were compared using weighted mean differences (MD). The risk of bias was assessed using the CLARITY Scale.The outcomes were recurrence, residual disease, air-bone gap (ABG), and air conductive (AC) thresholds.After screening 1036 publications, 17 retrospective cohort studies were selected. 1333 children were included; the overall mean age was ten years (SD 7.9), and the overall mean follow-up time was 5.9 years (SD 6.6). CWU and CWD techniques were performed in 60% (796) and 40% (537) cases. We did not find differences in cholesteatoma recurrence (RR: 1.50, 95% CI 0.94; 2.40; n = 544; I2 0%; Tau [2]: 0.00), or rates of residual cholesteatoma (RR 1.51, 95% CI 0.96; 2.38, n = 506; I2: 0%; Tau [2]: 0.00) in patients who underwent CWU and CWD mastoidectomy. The mean air-bone gap was lower with CWU than CWD (mean difference: 7.60, 95% CI -10.65; -4.54; n = 242; I2: 71%; Tau [2]: 5.98).and relevance: We show similar rates of recurrence and residual disease after either CWU or CWD tympanoplasty. Our results challenge the fundamental principle of CWD surgery as a standard technique, as there is no difference in rates of recurrence and residual disease in CWU and CWD. Moreover, audiometric results support CWU with improved hearing outcomes.PROSPERO identifier: CRD42020184029.

  View details for DOI 10.1016/j.ijporl.2023.111658

  View details for PubMedID 37666040

• Imaging guidance for cholesteatoma surgery using tissue autofluorescence. Journal of biomedical optics Yang, S., Farrell, J., Ye, S., Ahmad, I., Valdez, T. A. 2023; 28 (6): 066003

  Abstract

  Cholesteatoma is an expansile destructive lesion of the middle ear and mastoid, which can result in significant complications by eroding adjacent bony structures. Currently, there is an inability to accurately distinguish cholesteatoma tissue margins from middle ear mucosa tissue, causing a high recidivism rate. Accurately differentiating cholesteatoma and mucosa will enable a more complete removal of the tissue.Develop an imaging system to enhance the visibility of cholesteatoma tissue and margins during surgery.Cholesteatoma and mucosa tissue samples were excised from the inner ear of patients and illuminated with 405, 450, and 520 nm narrowband lights. Measurements were made with a spectroradiometer equipped with a series of different longpass filters. Images were obtained using a red-green-blue (RGB) digital camera equipped with a long pass filter to block reflected light.Cholesteatoma tissue fluoresced under 405 and 450 nm illumination. Middle ear mucosa tissue did not fluoresce under the same illumination and measurement conditions. All measurements were negligible under 520 nm illumination conditions. All spectroradiometric measurements of cholesteatoma tissue fluorescence can be predicted by a linear combination of emissions from keratin and flavin adenine dinucleotide. We built a prototype of a fluorescence imaging system using a 495 nm longpass filter in combination with an RGB camera. The system was used to capture calibrated digital camera images of cholesteatoma and mucosa tissue samples. The results confirm that cholesteatoma emits light when it is illuminated with 405 and 450 nm, whereas mucosa tissue does not.We prototyped an imaging system that is capable of measuring cholesteatoma tissue autofluorescence.

  View details for DOI 10.1117/1.JBO.28.6.066003

  View details for PubMedID 37334207

  View details for PubMedCentralID PMC10275381

• Topical Delivery of Elastic Liposomal Vesicles for Treatment of Middle and Inner Ear Diseases. ACS applied bio materials Kashfi Sadabad, R., Xia, A., Benkafadar, N., Faniku, C., Preciado, D., Yang, S., Valdez, T. A. 2022

  Abstract

  We present a topical drug delivery mechanism through the ear canal to the middle and inner ear using liposomal nanoparticles without disrupting the integrity of the tympanic membrane. The current delivery method provides a noninvasive and safer alternative to transtympanic membrane injections, ear tubes followed by ear drops administration, and systemic drug formulations. We investigate the capability of liposomal NPs, particularly transfersomes (TLipo), used as drug delivery vesicles to penetrate the tympanic membrane (TM) and round window membrane (RWM) with high affinity, specificity, and retention time. The TLipo is applied to the ear canal and found to pass through the tympanic membrane quickly in 3 h post drug administration. They are identified in the middle ear cavity 6 h and in the inner ear 24 h after drug administration. We performed cytotoxicity in vitro and ototoxicity in vivo studies. Cell viability shows no significant difference between the applied TLipo concentration and control. Furthermore, auditory brainstem response (ABR) reveals no hearing loss in 1 week and 1 month post-administration. Immunohistochemistry results demonstrate no evidence of hair cell loss in the cochlea at 1 month following TLipo administration. Together, the data suggested that TLipo can be used as a vehicle for topical drug delivery to the middle ear and inner ear.

  View details for DOI 10.1021/acsabm.2c00569

  View details for PubMedID 36179346

• Artificial intelligence and tele-otoscopy: A window into the future of pediatric otology. International journal of pediatric otorhinolaryngology Ezzibdeh, R., Munjal, T., Ahmad, I., Valdez, T. A. 2022; 160: 111229

  Abstract

  Telehealth in otolaryngology is gaining popularity as a potential tool for increased access for rural populations, decreased specialist wait times, and overall savings to the healthcare system. The adoption of telehealth has been dramatically increased by the COVID-19 pandemic limiting patients' physical access to hospitals and clinics. One of the key challenges to telehealth in general otolaryngology and otology specifically is the limited physical examination possible on the ear canal and middle ear. This is compounded in pediatric populations who commonly present with middle ear pathologies which can be challenging to diagnose even in the clinic. To address this need, various otoscopes have been designed to allow patients, their parents, or primary care providers to image the tympanic membrane and middle ear, and send data to otolaryngologists for review. Furthermore, the ability of these devices to capture images in digital format has opened the possibility of using artificial intelligence for quick and reliable diagnostic workup. In this manuscript, we provide a concise review of the literature regarding the efficacy of remote otoscopy, as well as recent efforts on the use of artificial intelligence in aiding otologic diagnoses.

  View details for DOI 10.1016/j.ijporl.2022.111229

  View details for PubMedID 35816971

• Use of Polysomnography and CPAP in Children Who Received Adenotonsillectomy, US 2004 to 2018. The Laryngoscope Qian, Z. J., Howard, J. M., Cohen, S. M., Jin, M. C., Bhargava, S., Cheng, A. G., Valdez, T. A. 2022

  Abstract

  OBJECTIVES: 1) To determine the prevalence polysomnogram (PSG) and continuous positive airway pressure (CPAP) therapy use in children who received adenotonsillectomy (AT) for sleep symptoms. 2) To identify health care disparities in these regards.STUDY DESIGN: Retrospective database analysis.METHODS: This study used data from Optum (Health Services Innovation Company) to identify 92,490 children who received AT for sleep symptoms between 2004 and 2018. Prevalence of preoperative PSG and postoperative PSG and CPAP were described. Clinical and demographic characteristics were compared between children who had preoperative PSG and those who did not. Characteristics of children with trisomy 21 (T21) were compared to assess PSG and CPAP use in a high-risk cohort. Predictive modeling was used to identify patient characteristics associated with postoperative PSG and CPAP use.RESULTS: Preoperative PSG was obtained in 5.5% of children overall and 33.2% of children with T21. Male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with preoperative PSG. Fewer than 3% of children received postoperative PSGs and approximately 3% went on to receive CPAP therapy postoperatively. Multiple logistic regression showed that age at surgery, male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with postoperative PSG and CPAP use.CONCLUSIONS AND RELEVANCE: This study described the prevalence pre-AT PSG use and post-AT PSG and CPAP use for persistent symptoms and identified sleep health care disparities in these regards. These results show that increased, equitable access to PSG is needed in children, particularly in the workup and treatment persistent symptoms after AT.LEVEL OF EVIDENCE: 4 Laryngoscope, 2022.

  View details for DOI 10.1002/lary.30103

  View details for PubMedID 35285524

• Centralized Otolaryngology Research Efforts: Stepping-stones to Innovation and Equity in Otolaryngology-Head and Neck Surgery. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Brenner, M. J., Nelson, R. F., Valdez, T. A., Moody-Antonio, S. A., Nathan, C. O., St John, M. A., Francis, H. W. 1800: 1945998211065465

  Abstract

  The Centralized Otolaryngology Research Efforts (CORE) grant program coordinates research funding initiatives across the subspecialties of otolaryngology-head and neck surgery. Modeled after National Institutes of Health study sections, CORE grant review processes provide comprehensive reviews of scientific proposals. The organizational structure and grant review process support grant-writing skills, attention to study design, and other components of academic maturation toward securing external grants from the National Institutes of Health or other agencies. As a learning community and a catalyst for scientific advances, CORE evaluates clinical, translational, basic science, and health services research. Amid the societal reckoning around long-standing social injustices and health inequities, an important question is to what extent CORE engenders diversity, equity, and inclusion for the otolaryngology workforce. This commentary explores CORE's track record as a stepping-stone for promoting equity and innovation in the specialty. Such insights can help maximize opportunities for cultivating diverse leaders across the career continuum.

  View details for DOI 10.1177/01945998211065465

  View details for PubMedID 34905423

• New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review 2020. OTO open Brenner, M. J., Shenson, J. A., Rose, A. S., Valdez, T. A., Takashima, M., Ahmed, O. G., Weissbrod, P. A., Hong, R. S., Djalilian, H., Wolf, J. S., Morrison, R. J., Santa Maria, P. L., Erbele, I. D. 2021; 5 (4): 2473974X211057035

  Abstract

  Objectives: To evaluate new drugs and devices relevant to otolaryngology-head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2020.Data Sources: Publicly available device and therapeutic approvals from ENT (ear, nose, and throat), anesthesia, neurology (neurosurgery), and plastic and general surgery FDA committees.Review Methods: Members of the American Academy of Otolaryngology-Head and Neck Surgery's Medical Devices and Drugs Committee reviewed new therapeutics and medical devices from a query of the FDA's device and therapeutic approvals. Two independent reviewers assessed the drug's or device's relevance to otolaryngology, classified to subspecialty field, with a critical review of available scientific literature.Conclusions: The Medical Devices and Drugs Committee reviewed 53 new therapeutics and 1094 devices (89 ENT, 140 anesthesia, 511 plastic and general surgery, and 354 neurology) approved in 2020. Ten drugs and 17 devices were considered relevant to the otolaryngology community. Rhinology saw significant improvements around image guidance systems; indications for cochlear implantation expanded; several new monoclonal therapeutics were added to head and neck oncology's armamentarium; and several new approvals appeared for facial plastics surgery, pediatric otolaryngology, and comprehensive otolaryngology.Implications for Practice: New technologies and pharmaceuticals offer the promise of improving how we care for otolaryngology patients. However, judicious introduction of innovations into practice requires a nuanced understanding of safety, advantages, and limitations. Working knowledge of new drugs and medical devices approved for the market helps clinicians tailor patient care accordingly.

  View details for DOI 10.1177/2473974X211057035

  View details for PubMedID 34790883

• Re-engineering the Surgeon-Scientist Pipeline: Advancing Diversity and Equity to Fuel Scientific Innovation. The Laryngoscope Munjal, T., Nathan, C., Brenner, M. J., Stankovic, K. M., Francis, H. W., Valdez, T. A. 2021

  View details for DOI 10.1002/lary.29800

  View details for PubMedID 34383298

• Comparing sleep studies in terms of the apnea-hypopnea index using the dedicated Shiny web application BIOMEDICAL SIGNAL PROCESSING AND CONTROL Mlynczak, M., Valdez, T. A., Kukwa, W. 2021; 68

  View details for DOI 10.1016/j.bspc.2021.102614

  View details for Web of Science ID 000670370300008

• Shortwave infrared otoscopy for diagnosis of middle ear effusions: a machine-learning-based approach. Scientific reports Kashani, R. G., Mlynczak, M. C., Zarabanda, D., Solis-Pazmino, P., Huland, D. M., Ahmad, I. N., Singh, S. P., Valdez, T. A. 2021; 11 (1): 12509

  Abstract

  Otitis media, a common disease marked by the presence of fluid within the middle ear space, imparts a significant global health and economic burden. Identifying an effusion through the tympanic membrane is critical to diagnostic success but remains challenging due to the inherent limitations of visible light otoscopy and user interpretation. Here we describe a powerful diagnostic approach to otitis media utilizing advancements in otoscopy and machine learning. We developed an otoscope that visualizes middle ear structures and fluid in the shortwave infrared region, holding several advantages over traditional approaches. Images were captured in vivo and then processed by a novel machine learning based algorithm. The model predicts the presence of effusions with greater accuracy than current techniques, offering specificity and sensitivity over 90%. This platform has the potential to reduce costs and resources associated with otitis media, especially as improvements are made in shortwave imaging and machine learning.

  View details for DOI 10.1038/s41598-021-91736-9

  View details for PubMedID 34131163

• New Age Mentoring and Disruptive Innovation-Navigating the Uncharted With Vision, Purpose, and Equity. JAMA otolaryngology-- head & neck surgery Ahmadmehrabi, S., Farlow, J. L., Wamkpah, N. S., Esianor, B. I., Brenner, M. J., Valdez, T. A., Malekzadeh, S., Bradford, C. R., Francis, H. W. 2021

  Abstract

  For individuals aspiring to a career in otolaryngology-head and neck surgery, mentorship can shape destiny. Mentorship helps assure safe passage into the specialty, and it influences the arc of professional development across the career continuum. Even before the novel coronavirus disease 2019 (COVID-19) pandemic, technology and social networking were transforming mentorship in otolaryngology. Now, in an increasingly virtual world, where in-person interactions are the exception, mentorship plays an even more pivotal role. Mentors serve as trusted guides, helping learners navigate accelerating trends toward early specialization, competency-based assessments, and key milestones. However, several structural barriers render the playing field unlevel. For medical students, cancellation of visiting clerkships, in-person rotations, and other face-to-face interactions may limit access to mentors. The pandemic and virtual landscape particularly threaten the already-leaky pipeline for underrepresented medical students. These challenges may persist into residency and later career stages, where structural inequities continue to subtly influence opportunities and pairings of mentors and mentees. Hence, overreliance on serendipitous encounters can exacerbate disparities, even amid societal mandates for equity. The decision to take deliberate steps toward mentoring outreach and engagement has profound implications for what otolaryngology will look like in years to come. This article introduces the concept of new age mentoring, shining a light on how to modernize practices. The key shifts are from passive to active engagement; from amorphous to structured relationships; and from hierarchical dynamics to bidirectional mentoring. Success is predicated on intentional outreach and purposefulness in championing diversity, equity, and inclusion in the progressively technology-driven landscape.

  View details for DOI 10.1001/jamaoto.2020.5448

  View details for PubMedID 33538788

• Short-Wave Infrared Fluorescence Chemical Sensor for Detection of Otitis Media. ACS sensors Yim, J. J., Singh, S. P., Xia, A., Kashfi-Sadabad, R., Tholen, M., Huland, D. M., Zarabanda, D., Cao, Z., Solis-Pazmino, P., Bogyo, M., Valdez, T. A. 2020

  Abstract

  Otitis media (OM) or middle ear infection is one of the most common diseases in young children around the world. The diagnosis of OM is currently performed using an otoscope to detect middle ear fluid and inflammatory changes manifested in the tympanic membrane. However, conventional otoscopy cannot visualize across the tympanic membrane or sample middle ear fluid. This can lead to low diagnostic certainty and overdiagnoses of OM. To improve the diagnosis of OM, we have developed a short-wave infrared (SWIR) otoscope in combination with a protease-cleavable biosensor, 6QC-ICG, which can facilitate the detection of inflammatory proteases in the middle ear with an increase in contrast. 6QC-ICG is a fluorescently quenched probe, which is activated in the presence of cysteine cathepsin proteases that are up-regulated in inflammatory immune cells. Using a preclinical model and custom-built SWIR otomicroscope in this proof-of-concept study, we successfully demonstrated the feasibility of robustly distinguishing inflamed ears from controls (p = 0.0006). The inflamed ears showed an overall signal-to-background ratio of 2.0 with a mean fluorescence of 81 ± 17 AU, while the control ear exhibited a mean fluorescence of 41 ± 11 AU. We envision that these fluorescently quenched probes in conjunction with SWIR imaging tools have the potential to be used as an alternate/adjunct tool for objective diagnosis of OM.

  View details for DOI 10.1021/acssensors.0c01272

  View details for PubMedID 33175516

• Dupilumab use in recalcitrant allergic fungal rhinosinusitis ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Lo, R. M., Liu, A. Y., Valdez, T. A., Gernez, Y. 2020; 125 (5): 617–19

  View details for Web of Science ID 000580645300029

• Combined web and haptic simulation system: A pilot study. International journal of pediatric otorhinolaryngology Valdez, T. A., Kudaravalli, S., Kavanagh, K. R. 2020; 138: 110371

  Abstract

  OBJECTIVES: Simulation education is increasingly used in otolaryngology training. The objective of this pilot study is to describe a mixed web-based and haptic modular platform for pediatric airway conditions.METHODS: A web-based modular case presentation and evaluation system were developed to correspond to a pediatric laryngeal condition represented on the haptic models created using 3D printing and silicone elastomer. The haptic microlaryngoscopy simulation training and web module were evaluated by participants using a Likert scale. The mixed modular apparatus systematized the open web platform and haptic simulator, videos, text, questions, and evaluation to provide a more comprehensive simulation experience.RESULTS: Seventeen otolaryngology trainees participated, each completing a post-simulation survey. All participants responded 4 or higher (agree or strongly agree) on the Likert scale that the virtual training and case presentations improved their understanding of the pediatric laryngeal conditions presented.CONCLUSION: A modular system constitutes a variety of web-based cases for evaluating, diagnosing, and performing procedures on a haptic surgical simulator taking the physician in training from diagnosis to treatment thereby expanding our current use of haptic simulators in surgical education to include case based learning and decision making.

  View details for DOI 10.1016/j.ijporl.2020.110371

  View details for PubMedID 33152964

• Prioritizing Diversity in Otolaryngology-Head and Neck Surgery: Starting a Conversation. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Truesdale, C. M., Baugh, R. F., Brenner, M. J., Loyo, M., Megwalu, U. C., Moore, C. E., Paddock, E. A., Prince, M. E., Strange, M., Sylvester, M. J., Thompson, D. M., Valdez, T. A., Xie, Y., Bradford, C. R., Taylor, D. J. 2020: 194599820960722

  Abstract

  Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.

  View details for DOI 10.1177/0194599820960722

  View details for PubMedID 33045901

• Cigarette smoke-induced changes in the murine vocal folds: a Raman spectroscopic observation. The Analyst Erickson-DiRenzo, E., Singh, S. P., Martinez, J. D., Sanchez, S. E., Easwaran, M., Valdez, T. A. 2020

  Abstract

  Raman spectroscopic methods are being projected as novel tools to study the early invisible molecular level changes in a label-free manner. In the present study, we have used Raman spectroscopy to explore the earliest biochemical changes in murine vocal folds in response to time-bound cigarette smoke exposure. Mice were exposed to cigarette smoke for 2 or 4-weeks through a customized smoke inhalation system. The larynx was collected and initial evaluations using standard methods of analysis such as histopathology and immunofluorescence was performed. Concurrent unstained sections were used for Raman imaging. Two common pathological features of vocal fold disorders including alterations in collagen content and epithelial hypercellularity, or hyperplasia, were observed. The mean spectra, principal component analysis, and Raman mapping also revealed differences in the collagen content and hypercellularity in the smoke exposed tissues. The differences in 2-week exposed tissues were found to be more prominent as compared to 4-week. This was attributed to adaptive responses and the already reported biphasic effects, which suggest that collagen synthesis is significantly reduced at higher cigarette smoke concentrations. Overall findings of the study are supportive of the prospective application of Raman imaging in monitoring changes due to cigarette smoke in the vocal folds.

  View details for DOI 10.1039/d0an01570a

  View details for PubMedID 32996925

• The Long "Race" to Diversity in Otolaryngology. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Tusty, M., Flores, B., Victor, R., Fassiotto, M., Maldonado, Y., Howard, J., Valdez, T. A. 2020: 194599820951132

  Abstract

  The number of health disparities disproportionately affecting minority communities continue to rise. Thus, it is imperative to assess whether equity within medical school enrollment and along the academic pipeline has mirrored this growth, especially among elite surgical specialties such as otolaryngology. Census and educational data from 2010 and 2018 were used to assess the current otolaryngology, surgery, and internal medicine physician and faculty workforce diversity across each stage of the academic medicine trajectory by race and ethnicity. We found that disparities exist in medical school enrollment for minority students such that Hispanic/Latinx representation was only 30% and Black representation only 50% of their respective proportions in the US population in 2018. Disparities in achieving full professorship were also observed across all 3 specialties but most prominently in otolaryngology, with 1% Black representation among otolaryngology professors in 2018. A collective strategy toward diversifying the otolaryngology workforce should be explored.

  View details for DOI 10.1177/0194599820951132

  View details for PubMedID 32838654

• How do we teach surgical residents in the COVID-19 era? Journal of surgical education Okland, T. S., Pepper, J., Valdez, T. A. 2020

  Abstract

  OBJECTIVE: In response to ongoing concerns regarding transmission of the novel coronavirus (COVID-19), surgical practice has changed for the foreseeable future. Practice guidelines recommend only urgent or emergent surgical procedures be performed to minimize viral transmission. This effectively limits standard training and practice for surgical residents. The purpose of this article is to describe opportunities in surgical simulation, and highlights the challenges associated with training in the COVID-19 era.DESIGN: This is a perspective summarizing the potential role of surgical simulation to target training gaps caused by decreased surgical caseloads.CONCLUSIONS: This manuscript concisely discusses simulation options available to training programs, including the novel concept of "surgical kits." These kits include all instruments necessary to simulate a procedure at home, effectively pairing safety and utility.

  View details for DOI 10.1016/j.jsurg.2020.05.030

  View details for PubMedID 32773336

• Letters to the Deaf: Present-Day Relevance of History's Earliest Social Analysis of Deafness. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Naples, J., Valdez, T. A. 2020: 194599819900492

  Abstract

  Harriet Martineau was a 19th-century sociologist who had a progressive form of deafness. Her 1834 essay, Letters to the Deaf, was the earliest historical document depicting the social challenges of hearing loss. Martineau details complex situations that hard-of-hearing people experienced in the 19th century such as social isolation due to frustrations with communication, physician shortcomings, limited music appreciation, and the stigma of hearing amplification devices. Her descriptions of these experiences are commonly faced by hard-of-hearing people in present-day society. Advancements in technology and recognition of the negative social impact of hearing loss have improved the social experience for the hard of hearing; however, social challenges remain relevant. In this article, we review Letters to the Deaf and note the ways in which this essay provides a dual perspective regarding how much we have advanced as a society and how much we still have to overcome in addressing the social challenges of hearing loss.

  View details for DOI 10.1177/0194599819900492

  View details for PubMedID 31959057

• The impact of COVID-19 on global disparities in surgical training in pediatric otolaryngology. International journal of pediatric otorhinolaryngology Munjal, T. n., Kavanagh, K. R., Ezzibdeh, R. M., Valdez, T. A. 2020; 138: 110267

  Abstract

  To assess global trends in otolaryngologic and non-otolaryngologic education in response to COVID-19, specifically with regard to surgical simulation and personnel reallocation needs in case of patient demand.Online survey.A multiple-choice survey regarding operative caseload and impact on resident education was sent to Otolaryngology residents and Pediatric Otolaryngology faculty globally. The survey was open for responses for ten days in March 2020.A total of 96 completed surveys were received across 22 countries. 87.5% of respondents reported that no supplementary operative education is being provided. Despite 71.43% of responses indicating that simulation was useful for all levels of residents, 20.95% of responses indicated that simulation is not possible at their institution, with the majority of these being skewed toward responses from South America.Despite the majority of respondents stating that simulation was helpful, there were disparities in access to simulation seen across countries. The results inform the need for a coordinated effort to expand educational efforts outside of the operating room and clinical environment. A major limitation of this study is the low domestic response rate.

  View details for DOI 10.1016/j.ijporl.2020.110267

  View details for PubMedID 32705990

• Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Tunkel, D. E., Anne, S. n., Payne, S. C., Ishman, S. L., Rosenfeld, R. M., Abramson, P. J., Alikhaani, J. D., Benoit, M. M., Bercovitz, R. S., Brown, M. D., Chernobilsky, B. n., Feldstein, D. A., Hackell, J. M., Holbrook, E. H., Holdsworth, S. M., Lin, K. W., Lind, M. M., Poetker, D. M., Riley, C. A., Schneider, J. S., Seidman, M. D., Vadlamudi, V. n., Valdez, T. A., Nnacheta, L. C., Monjur, T. M. 2020; 162 (1_suppl): S1–S38

  Abstract

  Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

  View details for DOI 10.1177/0194599819890327

  View details for PubMedID 31910111

• Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Tunkel, D. E., Anne, S. n., Payne, S. C., Ishman, S. L., Rosenfeld, R. M., Abramson, P. J., Alikhaani, J. D., Benoit, M. M., Bercovitz, R. S., Brown, M. D., Chernobilsky, B. n., Feldstein, D. A., Hackell, J. M., Holbrook, E. H., Holdsworth, S. M., Lin, K. W., Lind, M. M., Poetker, D. M., Riley, C. A., Schneider, J. S., Seidman, M. D., Vadlamudi, V. n., Valdez, T. A., Nnacheta, L. C., Monjur, T. M. 2020; 162 (1): 8–25

  Abstract

  Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients.The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

  View details for DOI 10.1177/0194599819889955

  View details for PubMedID 31910122

• Sublingual indocyanine green films for non-invasive swallowing assessment and inflammation detection through NIR/SWIR optical imaging. Scientific reports Beringhs, A. O., Singh, S. P., Valdez, T. A., Lu, X. n. 2020; 10 (1): 14003

  Abstract

  Indocyanine green (ICG) is the most commonly used FDA-approved agent for clinical optical imaging, administered through injections only, due to its poor membrane permeability. Although ICG has vast potential for non-invasive non-radioactive imaging in patients, the clinical applications are limited by the invasive administration and short half-life in blood circulation. To expand the clinical value of ICG, non-toxic chitosan-based ICG-loaded films were designed for sublingual administration for near-infrared (NIR) and short-wave infrared (SWIR) optical imaging. Two film formulations were developed with different ICG release rates. Mold-casted self-emulsifying films rapidly released ICG (80% in 4 h) in the form of nanosized droplets, which were mostly swallowed and produced significant contrast of upper digestive tract to enable in vivo swallowing evaluations using NIR/SWIR imaging. Regular films released ICG slowly (80% in 25 h), allowing for steady absorption of ICG to systemic circulation. Inflammation in mouse feet was detected within 30 min after sublingual administration with a 1.43-fold fluorescence increase within 1 h at the inflammation sites, comparable to a 1.76-fold increase through intravenous injection. Administering ICG using sublingual films displayed notable potential for non-invasive diagnosis and monitoring of inflammatory conditions and swallowing disorders, addressing a current need for alternatives to ICG parenteral administration.

  View details for DOI 10.1038/s41598-020-71054-2

  View details for PubMedID 32814802

• Joint Apnea and Body Position Analysis for Home Sleep Studies Using a Wireless Audio and Motion Sensor IEEE ACCESS Mlynczak, M., Valdez, T. A., Kukwa, W. 2020; 8: 170579–87

  View details for DOI 10.1109/ACCESS.2020.3024122

  View details for Web of Science ID 000572902600001

• Suppurative Thyroiditis: A Management Paradigm Based on Microbiology. Pediatric emergency care Pereira, K. D., Highstein, M. J., Greenwell, A. G., Isaiah, A. n., Valdez, T. A. 2020

  Abstract

  The aim of this study was to determine if microbiological cultures can guide management of suppurative thyroiditis.This study is a retrospective case series set in 2 tertiary care academic hospitals.The microbiological cultures from patients with suppurative thyroiditis who underwent incision and drainage from July 2004 to June 2018 were reviewed. Those who had confirmed pyriform sinus tracts and underwent surgical intervention were included in the study.Fifteen patients satisfied the criteria for inclusion. All had confirmed pyriform sinus tracts and underwent successful intervention. Endoscopic cautery was the most common intervention followed by complete open excision. Five cultures grew alpha Streptococcus, 6 had Eikenella, and 4 Prevotella. Combinations of Eikenella + Prevotella were seen in 3, and 1 sample had all 3 bacteria. Two cultured methicillin-susceptible Staphylococcus aureus alone. One culture was sterile.The presence of oral flora in an intrathyroidal abscess is confirmatory evidence of a pyriform sinus tract. Further investigations are not needed, and early definitive intervention can be planned.

  View details for DOI 10.1097/PEC.0000000000002062

  View details for PubMedID 33003129

• Panel 1: Biotechnology, biomedical engineering and new models of otitis media. International journal of pediatric otorhinolaryngology Gisselsson-Solen, M., Tahtinen, P. A., Ryan, A. F., Mulay, A., Kariya, S., Schilder, A. G., Valdez, T. A., Brown, S., Nolan, R. M., Hermansson, A., van Ingen, G., Marom, T. 2019: 109833

  Abstract

  OBJECTIVE: To summarize recently published key articles on the topics of biomedical engineering, biotechnology and new models in relation to otitis media (OM).DATA SOURCES: Electronic databases: PubMed, Ovid Medline, Cochrane Library and Clinical Evidence (BMJ Publishing).REVIEW METHODS: Articles on biomedical engineering, biotechnology, material science, mechanical and animal models in OM published between May 2015 and May 2019 were identified and subjected to review. A total of 132 articles were ultimately included.RESULTS: New imaging technologies for the tympanic membrane (TM) and the middle ear cavity are being developed to assess TM thickness, identify biofilms and differentiate types of middle ear effusions. Artificial intelligence (AI) has been applied to train software programs to diagnose OM with a high degree of certainty. Genetically modified mice models for OM have further investigated what predisposes some individuals to OM and consequent hearing loss. New vaccine candidates protecting against major otopathogens are being explored and developed, especially combined vaccines, targeting more than one pathogen. Transcutaneous vaccination against non-typeable Haemophilus influenzae has been successfully tried in a chinchilla model. In terms of treatment, novel technologies for trans-tympanic drug delivery are entering the clinical domain. Various growth factors and grafting materials aimed at improving healing of TM perforations show promising results in animal models.CONCLUSION: New technologies and AI applications to improve the diagnosis of OM have shown promise in pre-clinical models and are gradually entering the clinical domain. So are novel vaccines and drug delivery approaches that may allow local treatment of OM.IMPLICATIONS FOR PRACTICE: New diagnostic methods, potential vaccine candidates and the novel trans-tympanic drug delivery show promising results, but are not yet adapted to clinical use.

  View details for DOI 10.1016/j.ijporl.2019.109833

  View details for PubMedID 31901291

• Identification of early inflammatory changes in the tympanic membrane with Raman spectroscopy. The Analyst Singh, S. P., Xia, A., Tusty, M., Victorovich Malkovskiy, A., Easwaran, M., Zarabanda, D., Valdez, T. A. 2019

  Abstract

  The tympanic membrane (TM) is a dynamic structure that separates the middle ear from the external auditory canal. It is also integral for the transmission of sound waves. In this study, we demonstrate the feasibility of using Raman spectroscopy to identify early chemical changes resulting from inflammation in the TM that can serve as an indicator of acute otitis media. Bacterial lipopolysaccharide (LPS) was injected trans-tympanicaly in a murine model. Presence of inflammatory response was assessed with binocular microscopy, confirmed with histopathology and immunofluorescence staining. Successful discrimination suggesting spectral differences among the control and LPS treated groups was achieved using principal component analysis. Raman imaging revealed major differences in collagen distribution and nucleic acid content. Image segmentation analysis on the trichrome stained tissue sections was performed to corroborate the Raman spectra. The spectral co-localization study suggests changes in the expression of collagen IV specific signals in LPS treated samples. The overall findings of the study support prospective application of RS in the diagnosis and therapeutic monitoring of otitis media.

  View details for DOI 10.1039/c9an01772k

  View details for PubMedID 31612878

• 3D printed myringotomy and tube simulation as an introduction to otolaryngology for medical students. International journal of pediatric otorhinolaryngology Sparks, D., Kavanagh, K. R., Vargas, J. A., Valdez, T. A. 2019; 128: 109730

  Abstract

  OBJECTIVES: Surgical simulation models have been shown to improve surgical skill and confidence for surgical residents before real life procedures. Surgical simulators can be similarly applied in undergraduate medical education as a tool to introduce students to the field of otolaryngology.METHODS: Ear models were created using 3D printing and high-performance silicone. Twenty medical students participated in a slide presentation and a myringotomy tube simulation station, each completing a pre- and post-survey using a 5-point Likert scale.RESULTS: A previously validated 3D myringotomy simulator was used. Twenty medical student volunteers participated in the simulation including 14 first-year and 6 s-year medical students. None of the participating students reported observing myringotomy and placement of tympanostomy tubes before the session. Medical student participants rated their knowledge of the steps of the procedure and where to insert the tympanostomy tube at 2 (2 = disagree) or below with a mean of 1.35 SD = 0.47 and 1.2 SD = 0.41 respectively. At the completion of the educational session, the medical students rated their knowledge of the steps of the procedure as significantly improved at 4.45 SD = 0.6 (p = 0.00001).DISCUSSION: We found that medical students with no prior exposure to ear anatomy or surgical training were able to use the simulator as an introduction to the specialty. There was a perceived improvement in their medical knowledge and basics of a procedural skill.CONCLUSION: Medical schools can provide an inexpensive, safe, procedural practice tool using 3D printing as an introduction for students interested in surgical procedures.

  View details for DOI 10.1016/j.ijporl.2019.109730

  View details for PubMedID 31634651

• Biochemical Changes in Irradiated Oral Mucosa: A FTIR Spectroscopic Study. Biosensors Ukkonen, H., Vuokila, S., Mikkonen, J. J., Dekker, H., Schulten, E. A., Bloemena, E., Koistinen, A., Valdez, T. A., Kullaa, A. M., Singh, S. P. 2019; 9 (1)

  Abstract

  Radiation exposure during the course of treatment in head and neck cancer (HNC) patients can induce both structural and biochemical anomalies. The present study is focused on utilizing infrared imaging for the identification of the minor biochemical alterations in the oral mucosa. Chemical maps generated using glycoprotein band indicates its differential distribution along the superficial layer. Spectra extracted from this layer suggests changes in overall nucleic acid and protein content in response to the therapeutic irradiation. Discrimination among control and irradiated groups have been achieved using principal component analysis. Findings of this preliminary study further support prospective utilization of Fourier Transform InfraRed (FTIR) imaging as a non-destructive, label-free tool for objective assessment of the oral mucosa in patient groups with or without radiation therapy.

  View details for PubMedID 30642117

• Integration of Diffraction Phase Microscopy and Raman Imaging for Label-free Morpho-molecular Assessment of Live Cells. Journal of biophotonics Pandey, R., Zhou, R., Bordett, R., Hunter, C., Glunde, K., Barman, I., Valdez, T., Finck, C. 2018: e201800291

  Abstract

  Label-free quantitative imaging is highly desirable for studying live cells by extracting pathophysiological information without perturbing cell functions. Here we demonstrate a novel label-free multimodal optical imaging system with the capability of providing comprehensive morphological and molecular attributes of live cells. Our morpho-molecular microscopy (3M) system draws on the combined strength of quantitative phase microscopy (QPM) and Raman microscopy to probe the morphological features and molecular fingerprinting characteristics of each cell under observation. While the common-path geometry of our QPM system allows for highly sensitive phase measurement, the Raman microscopy is equipped with dual excitation wavelengths and utilizes the same detection and dispersion system, making it a distinctive multi-wavelength system with a small footprint. We demonstrate the applicability the 3M system by investigating nucleated and non-nucleated cells. This integrated, label-free platform has a promising potential in preclinical research, as well as in clinical diagnosis in the near future. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30421505

• Teaching a tracheotomy handoff tool to pediatric first responders INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Murray, N., Valdez, T. A., Hughes, A. L., Kavanagh, K. R. 2018; 114: 120–23

  View details for DOI 10.1016/j.ijporl.2018.08.003

  View details for Web of Science ID 000447580700022

• Initial findings of shortwave infrared otoscopy in a pediatric population. International journal of pediatric otorhinolaryngology Valdez, T. A., Carr, J. A., Kavanagh, K. R., Schwartz, M., Blake, D., Bruns, O., Bawendi, M. 2018; 114: 15–19

  Abstract

  OBJECTIVE: To evaluate the feasibility of Shortwave infrared (SWIR) otoscopy in a pediatric population and establish differences with visible otoscopy.METHODS: Pediatric patients 3 years of age and older seen in the otolaryngology clinic with an audiogram and tympanogram obtained within a week of the visit were recruited for video otoscopy using visible light otoscopy and SWIR otoscopy. Videos were rated by two otolaryngologists based on ability to identify the promontory, ability to identify the ossicular chain and presence or absence of middle ear fluid.RESULTS: A total of 74 video recordings of ears were obtained in 20 patients. We obtained interpretable images in 63/74 (85.1%) ears. There was no statistical significance between ability to perform SWIR otoscopy versus white light video otoscopy as indicated by a p-value of 0.376. There was high inter-rater agreement for identification of both the promontory and the ossicular chain with Kappa values of 0.81 and 0.92 respectively. There was statistical significance between SWIR otoscopy and visible otoscopy in the ability to image the promontory (p = 0.012) and the ossicular chain (p = 0.010). Increased contrast of middle ear fluid was seen in SWIR otoscopy when compared to visible otoscopy.CONCLUSION: SWIR otoscopy is feasible in a pediatric population and could offer some advantages over visible light otoscopy such as better visualization of the middle ear structures through the tympanic membrane and increased contrast for middle ear effusions.

  View details for PubMedID 30262355

• Teaching a tracheotomy handoff tool to pediatric first responders. International journal of pediatric otorhinolaryngology Murray, N., Valdez, T. A., Hughes, A. L., Kavanagh, K. R. 2018; 114: 120–23

  Abstract

  INTRODUCTION: The Critical Airway Risk Evaluation (CARE) system is an airway classification system we designed to improve handoffs between caregivers by describing the risk of a patient's airway above the tracheotomy tube, and therefore the correct resuscitation maneuvers in the event of an airway emergency. It is designed to quickly communicate 3 categories: 1-easily intubatable; 2-intubatable with specialized techniques or equipment; or 3-not intubatable. We have demonstrated previously that the system is easily taught to and used by pediatric otolaryngologists. For this system to be useful, it must be usable by a broader group, including first responders to a tracheostomy related airway emergency. The objective of this study is to analyze the reliability of teaching and ease of learning the CARE system among practicing otolaryngologists, otolaryngology residents, and pediatric residents.METHODS: A brief tutorial was designed to introduce the scale and was presented to practicing otolaryngologists, otolaryngology residents, and pediatrics residents. A 30-point questionnaire was administered in which patient's airways and airway management techniques were described. Participants were asked to classify each example according to the CARE system. Statistical analysis was performed using Student's t-test and Fleiss' kappa reliability.RESULTS: A total of 66 physicians participated in the study. The pediatric residents correctly identified the patients' airway class 89% of the time (26.6/30 ± SD = 2.9). Otolaryngology attendings and residents answered correctly 92% of the time (27.7/30 ± SD = 2.9), which was not statistically different (p = 0.23). Inter-rater reliability was also substantial among all groups, with a Fleiss' kappa greater than 0.7 for all groups.CONCLUSIONS: This study demonstrates that the system can be taught to pediatrics residents as effectively as it can be taught to otolaryngology residents and practicing otolaryngologists and, therefore, can be effectively utilized in inter-disciplinary handoffs to facilitate information transfer to potential first responders.

  View details for PubMedID 30262348

• Initial findings of shortwave infrared otoscopy in a pediatric population INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Valdez, T. A., Carr, J. A., Kavanagh, K. R., Schwartz, M., Blake, D., Bruns, O., Bawendi, M. 2018; 114: 15–19

  View details for DOI 10.1016/j.ijporl.2018.08.024

  View details for Web of Science ID 000447580700004

• 3-Dimensional printed haptic simulation model to teach incomplete cleft palate surgery in an international setting INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Cote, V., Schwartz, M., Vargas, J., Canfarotta, M., Kavanagh, K. R., Hamdan, U., Valdez, T. A. 2018; 113: 292–97

  Abstract

  Cleft palate is one of the most common congenital anomalies, yet surgical repair remains challenging and can lead to significant complications in the hands of inexperienced surgeons. There is a great need for the development of a simulation model that will allow surgeons worldwide to learn and practice the intricate skills needed for cleft palate surgery.1. To develop a low-cost incomplete cleft palate simulation model using additive manufacturing technology (3D printing). 2. To evaluate its validity and utility to teach palatoplasty in a global health care setting.Three-dimensional models of a soft palate cleft and an incomplete hard and soft palate cleft were developed using 3D printing and silicone casting. The cost and time of assembly of the 3D printed models were calculated. The models were then assessed for validity by cleft surgeons and trainees during a cleft mission in Ecuador. 3D models were assessed for resemblance to anatomy and tissue characteristics, the ability to incise the soft tissue, dissect and reposition the palatal flaps, and the ease of suture placement. Models were rated using the Likeness to Human Tissue Scale.Cleft palate simulators were successfully developed using 3D printing and silicone casting. Participants reported that models provided a realistic representation of human anatomy and were adequate for novice surgeons to practice the procedure. The models were portable, low cost, and easily assembled.The use of 3D printed haptic simulation models for teaching and learning cleft palate repair techniques could enhance skill acquisition and possibly improve surgical outcomes. In outreach settings, it could help achieve local, sustainable comprehensive care for cleft palate patients.

  View details for PubMedID 30174004

• Differential diagnosis of otitis media with effusion using label-free Raman spectroscopy: A pilot study JOURNAL OF BIOPHOTONICS Pandey, R., Zhang, C., Kang, J. W., Desai, P. M., Dasari, R. R., Barman, I., Valdez, T. A. 2018; 11 (6)

  View details for DOI 10.1002/jbio.201700259

  View details for Web of Science ID 000434641700004

• iPhone otoscopes: Currently available, but reliable for tele-otoscopy in the hands of parents? INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Shah, M., Sohal, M., Valdez, T. A., Grindle, C. R. 2018; 106: 59–63

  Abstract

  Tele-otoscopy has been validated for tympanostomy surveillance and remote diagnosis when images are recorded by trained professionals. The CellScope iPhone Otoscope is a device that may be used for tele-otoscopy and it enables parents to record their children's ear examinations and send the films for remote physician diagnosis. This study aims to determine the ability to diagnose, and the reliability of the diagnosis when utilizing video exams obtained by a parent versus video exams obtained by an otolaryngologist.Parents of children ages 17 years or younger attempted recordings of the tympanic membrane of their children with the CellScope after a video tutorial; a physician subsequently used the device to record the same ear. Recordings occurred prior to standard pediatric otolaryngology office evaluation. Later, a remote pediatric otolaryngologist attempted diagnosis solely based on the videos, blinded to whether the examination was filmed by a parent or physician. Interrater reliability between video diagnosis and original diagnosis on pneumatic otoscopy was measured, and objective tympanic membrane landmarks visualized on the films were recorded.Eighty ears were enrolled and recorded. There was low interrater agreement (k = 0.42) between diagnosis based on parent videos as compared with pneumatic otoscopy. There was high agreement (k = 0.71) between diagnosis based on physician videos and pneumatic otoscopy. Physician videos and parent videos had only slight agreement on objective landmarks identified (k = 0.087).iPhone otoscopy provides reliable tele-otoscopy images in when used by trained professionals but, currently, images obtained by parents are not suitable for use in diagnosis.

  View details for PubMedID 29447893

• Using simulators to teach pediatric airway procedures in an international setting INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Schwartz, M. A., Kavanagh, K. R., Frampton, S. J., Bruce, I. A., Valdez, T. A. 2018; 104: 178–81

  Abstract

  There has been a growing shift towards endoscopic management of laryngeal procedures in pediatric otolaryngology. There still appears to be a shortage of pediatric otolaryngology programs and children's hospitals worldwide where physicians can learn and practice these skills. Laryngeal simulation models have the potential to be part of the educational training of physicians who lack exposure to relatively uncommon pediatric otolaryngologic pathology.The objective of this study was to assess the utility of pediatric laryngeal models to teach laryngeal pathology to physicians at an international meeting.Pediatric laryngeal models were assessed by participants at an international pediatric otolaryngology meeting. Participants provided demographic information and previous experience with pediatric airways. Participants then performed simulated surgery on these models and evaluated them using both a previously validated Tissue Likeness Scale and a pre-simulation to post-simulation confidence scale.Participants reported significant subjective improvement in confidence level after use of the simulation models (p < 0.05). Participants reported realistic representations of human anatomy and pathology. The models' tissue mechanics were adequate to practice operative technique including the ability to incise, suture, and suspend models.The pediatric laryngeal models demonstrate high quality anatomy, which is easy manipulated with surgical instruments. These models allow both trainees and surgeons to practice time-sensitive airway surgeries in a safe and controlled environment.

  View details for PubMedID 29287862

• Differential diagnosis of otitis media with effusion using label-free Raman spectroscopy: A pilot study. Journal of biophotonics Pandey, R., Zhang, C., Kang, J. W., Desai, P. M., Dasari, R. R., Barman, I., Valdez, T. A. 2017

  Abstract

  Otitis media with effusion (OME) is an important and common condition affecting hearing in pediatric patients characterized by the presence of fluid in the middle ear space. The fluid is normally described as serous or mucoid based on differences in the fluid viscosity. The differential diagnosis of two OMEs, namely serous and mucoid is of significant clinical value because while the former is self-limiting, surgical procedure is commonly required for the latter. However, accurate identification of fluid types remains a challenging target unattainable with current clinical modalities due to unavailability of nonperturbative molecular tools. Here, we report an emerging spectroscopy approach featuring Raman scattering and multivariate analysis of spectral patterns to discern serous and mucoid fluids, obtained from pediatric patients undergoing myringotomy and tube placement, by providing information of differentially expressed molecules with high specificity. We demonstrate the feasibility of Raman spectroscopy-based approach to categorize middle ear effusion based on the characteristic spectral markers, notably of mucin, with classification accuracy of 91% and 93% for serous and mucoid, respectively. Our findings pave the way for further development of such a tool for fully noninvasive application that will lead to objective and accurate diagnosis thereby reducing unnecessary visits and surgical procedures.

  View details for PubMedID 29232053

• Pediatric laryngeal simulator using 3D printed models: A novel technique LARYNGOSCOPE Kavanagh, K. R., Cote, V., Tsui, Y., Kudernatsch, S., Peterson, D. R., Valdez, T. A. 2017; 127 (4): E132-E137

  Abstract

  Simulation to acquire and test technical skills is an essential component of medical education and residency training in both surgical and nonsurgical specialties. High-quality simulation education relies on the availability, accessibility, and reliability of models. The objective of this work was to describe a practical pediatric laryngeal model for use in otolaryngology residency training. Ideally, this model would be low-cost, have tactile properties resembling human tissue, and be reliably reproducible.Pediatric laryngeal models were developed using two manufacturing methods: direct three-dimensional (3D) printing of anatomical models and casted anatomical models using 3D-printed molds. Polylactic acid, acrylonitrile butadiene styrene, and high-impact polystyrene (HIPS) were used for the directly printed models, whereas a silicone elastomer (SE) was used for the casted models.The models were evaluated for anatomic quality, ease of manipulation, hardness, and cost of production. A tissue likeness scale was created to validate the simulation model. Fleiss' Kappa rating was performed to evaluate interrater agreement, and analysis of variance was performed to evaluate differences among the materials.The SE provided the most anatomically accurate models, with the tactile properties allowing for surgical manipulation of the larynx. Direct 3D printing was more cost-effective than the SE casting method but did not possess the material properties and tissue likeness necessary for surgical simulation.The SE models of the pediatric larynx created from a casting method demonstrated high quality anatomy, tactile properties comparable to human tissue, and easy manipulation with standard surgical instruments. Their use in a reliable, low-cost, accessible, modular simulation system provides a valuable training resource for otolaryngology residents.N/A. Laryngoscope, 127:E132-E137, 2017.

  View details for DOI 10.1002/lary.26326

  View details for Web of Science ID 000397572700003

• Tracheostomy for Severe Pediatric Obstructive Sleep Apnea: Indications and Outcomes. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Rizzi, C. J., Amin, J. D., Isaiah, A., Valdez, T. A., Jeyakumar, A., Smart, S. E., Pereira, K. D. 2017: 194599817702369-?

  Abstract

  Objectives (1) To describe characteristics of pediatric patients undergoing tracheostomy for obstructive sleep apnea (OSA). (2) To highlight perioperative events and outcomes of the procedure. Study Design Case series with chart review. Setting Four tertiary care academic children's hospitals. Subjects and Methods Twenty-nine children aged <18 years from January 1, 2010, to December 31, 2015, who underwent tracheostomy for severe OSA, defined as an apnea-hypopnea index (AHI) >10, were included in the study. Data on patient characteristics, polysomnographic findings, comorbidities, and perioperative events and outcomes were collected and analyzed. Results Twenty-nine patients were included. Mean age at tracheostomy was 2.0 years (95% CI, -2.2 to 6.2). Mean body mass index z score was -1.2 (95% CI, -4.9 to -2.5). Mean preoperative AHI was 60.2 (95% CI, -15.7 to 136.1). Mean postoperative intensive care unit stay was 23.2 days (95% CI, 1.44-45.0). One procedure was complicated by bronchospasm. Thirteen patients had craniofacial abnormalities; 10 had a neurologic disorder resulting in hypotonia; and 5 had a diagnosis of laryngomalacia. Mean follow-up was 30.6 months (95% CI, -10.4 to 71.6). Six patients were decannulated, with a mean time to decannulation of 40.8 months (95% CI, 7.9-73.7). Five patients underwent capped sleep study prior to decannulation with a mean AHI of 6.6 (95% CI, -9.9 to 23.1) and a mean oxygen nadir of 90.0% (95% CI, 80%-100%). Conclusion OSA is an uncommon indication for tracheostomy in children. Patients who require the procedure usually have an associated syndromic diagnosis resulting in upper airway obstruction. The majority of children who undergo tracheostomy for OSA will remain dependent at 24 months.

  View details for DOI 10.1177/0194599817702369

  View details for PubMedID 28417683

• Panel 8: Report on Recent Advances in Molecular and Cellular Biochemistry. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Preciado, D., Granath, A., Lin, J., Val, S., Kurabi, A., Johnston, N., Vijayasekaran, S., Valdez, T., Depireux, D., Hermansson, A. 2017; 156 (4_): S106-S113

  Abstract

  Objectives To update the medical literature on recent cellular and molecular advances in otitis media disease models with a principal focus on developments in the past 5 years. We also aim to explain recent translational advances in cellular and molecular biology that have influenced our understanding and management of otitis media. Data Sources PubMed-indexed peer-reviewed articles. Review Methods A comprehensive review of the literature was conducted with the term otitis media and the following search terms: molecular biology, cell biology, innate immunity, oxidative stress, mucins, molecular diagnostics. Included articles were published in the English language from January 1, 2010, to July 31, 2015. Implications for Practice The molecular understanding of otitis media disease progression has rapidly advanced over the last 5 years. The roles of inflammation, mucins, and cell signaling mechanisms have been elucidated and defined. Advances in the field provide a plethora of opportunities for innovative molecular targeting in the development of novel therapeutic strategies for otitis media.

  View details for DOI 10.1177/0194599816658290

  View details for PubMedID 28372528

• Pediatric laryngeal simulator using 3D printed models: A novel technique. Laryngoscope Kavanagh, K. R., Cote, V., Tsui, Y., Kudernatsch, S., Peterson, D. R., Valdez, T. A. 2017; 127 (4): E132-E137

  Abstract

  Simulation to acquire and test technical skills is an essential component of medical education and residency training in both surgical and nonsurgical specialties. High-quality simulation education relies on the availability, accessibility, and reliability of models. The objective of this work was to describe a practical pediatric laryngeal model for use in otolaryngology residency training. Ideally, this model would be low-cost, have tactile properties resembling human tissue, and be reliably reproducible.Pediatric laryngeal models were developed using two manufacturing methods: direct three-dimensional (3D) printing of anatomical models and casted anatomical models using 3D-printed molds. Polylactic acid, acrylonitrile butadiene styrene, and high-impact polystyrene (HIPS) were used for the directly printed models, whereas a silicone elastomer (SE) was used for the casted models.The models were evaluated for anatomic quality, ease of manipulation, hardness, and cost of production. A tissue likeness scale was created to validate the simulation model. Fleiss' Kappa rating was performed to evaluate interrater agreement, and analysis of variance was performed to evaluate differences among the materials.The SE provided the most anatomically accurate models, with the tactile properties allowing for surgical manipulation of the larynx. Direct 3D printing was more cost-effective than the SE casting method but did not possess the material properties and tissue likeness necessary for surgical simulation.The SE models of the pediatric larynx created from a casting method demonstrated high quality anatomy, tactile properties comparable to human tissue, and easy manipulation with standard surgical instruments. Their use in a reliable, low-cost, accessible, modular simulation system provides a valuable training resource for otolaryngology residents.N/A. Laryngoscope, 127:E132-E137, 2017.

  View details for DOI 10.1002/lary.26326

  View details for PubMedID 27730649

• Noninvasive Monitoring of Blood Glucose with Raman Spectroscopy ACCOUNTS OF CHEMICAL RESEARCH Pandey, R., Paidi, S. K., Valdez, T. A., Zhang, C., Spegazzini, N., Dasari, R. R., Barman, I. 2017; 50 (2): 264-272

  Abstract

  The successful development of a noninvasive blood glucose sensor that can operate reliably over sustained periods of time has been a much sought after but elusive goal in diabetes management. Since diabetes has no well-established cure, control of elevated glucose levels is critical for avoiding severe secondary health complications in multiple organs including the retina, kidney and vasculature. While fingerstick testing continues to be the mainstay of blood glucose detection, advances in electrochemical sensing-based minimally invasive approaches have opened the door for alternate methods that would considerably improve the quality of life for people with diabetes. In the quest for better sensing approaches, optical technologies have surfaced as attractive candidates as researchers have sought to exploit the endogenous contrast of glucose, notably its absorption, scattering, and polarization properties. Vibrational spectroscopy, especially spontaneous Raman scattering, has exhibited substantial promise due to its exquisite molecular specificity and minimal interference of water in the spectral profiles acquired from the blood-tissue matrix. Yet, it has hitherto been challenging to leverage the Raman scattering signatures of glucose for prediction in all but the most basic studies and under the least demanding conditions. In this Account, we discuss the newly developed array of methodologies that address the key challenges in measuring blood glucose accurately using Raman spectroscopy and unlock new prospects for translation to sustained noninvasive measurements in people with diabetes. Owing to the weak intensity of spontaneous Raman scattering, recent research has focused on enhancement of signals from the blood constituents by designing novel excitation-collection geometries and tissue modulation methods while our attempts have led to the incorporation of nonimaging optical elements. Additionally, invoking mass transfer modeling into chemometric algorithms has not only addressed the physiological lag between the actual blood glucose and the measured interstitial fluid glucose values but also offered a powerful tool for predictive measurements of hypoglycemia. This framework has recently been extended to provide longitudinal tracking of glucose concentration without necessitating extensive a priori concentration information. These findings are advanced by the results of recent glucose tolerance studies in human subjects, which also hint at the need for designing nonlinear calibration models that can account for subject-to-subject variations in skin heterogeneity and hematocrit levels. Together, the emerging evidence underscores the promise of a blood withdrawal-free optical platform-featuring a combination of high-throughput Raman spectroscopic instrumentation and data analysis of subtle variations in spectral expression-for diabetes screening in the clinic and, ultimately, for personalized monitoring.

  View details for DOI 10.1021/acs.accounts.6b00472

  View details for Web of Science ID 000394724500014

  View details for PubMedID 28071894

• Using the shortwave infrared to image middle ear pathologies PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Carr, J. A., Valdez, T. A., Bruns, O. T., Bawendi, M. G. 2016; 113 (36): 9989-9994

  Abstract

  Visualizing structures deep inside opaque biological tissues is one of the central challenges in biomedical imaging. Optical imaging with visible light provides high resolution and sensitivity; however, scattering and absorption of light by tissue limits the imaging depth to superficial features. Imaging with shortwave infrared light (SWIR, 1-2 μm) shares many advantages of visible imaging, but light scattering in tissue is reduced, providing sufficient optical penetration depth to noninvasively interrogate subsurface tissue features. However, the clinical potential of this approach has been largely unexplored because suitable detectors, until recently, have been either unavailable or cost prohibitive. Here, taking advantage of newly available detector technology, we demonstrate the potential of SWIR light to improve diagnostics through the development of a medical otoscope for determining middle ear pathologies. We show that SWIR otoscopy has the potential to provide valuable diagnostic information complementary to that provided by visible pneumotoscopy. We show that in healthy adult human ears, deeper tissue penetration of SWIR light allows better visualization of middle ear structures through the tympanic membrane, including the ossicular chain, promontory, round window niche, and chorda tympani. In addition, we investigate the potential for detection of middle ear fluid, which has significant implications for diagnosing otitis media, the overdiagnosis of which is a primary factor in increased antibiotic resistance. Middle ear fluid shows strong light absorption between 1,400 and 1,550 nm, enabling straightforward fluid detection in a model using the SWIR otoscope. Moreover, our device is easily translatable to the clinic, as the ergonomics, visual output, and operation are similar to a conventional otoscope.

  View details for DOI 10.1073/pnas.1610529113

  View details for Web of Science ID 000383094500027

  View details for PubMedID 27551085

• Volume estimation of tonsil phantoms using an oral camera with 3D imaging BIOMEDICAL OPTICS EXPRESS Das, A. J., Valdez, T. A., Vargas, J. A., Saksupapchon, P., Rachapudi, P., Ge, Z., Estrada, J. C., Raskar, R. 2016; 7 (4): 1445-1457

  Abstract

  Three-dimensional (3D) visualization of oral cavity and oropharyngeal anatomy may play an important role in the evaluation for obstructive sleep apnea (OSA). Although computed tomography (CT) and magnetic resonance (MRI) imaging are capable of providing 3D anatomical descriptions, this type of technology is not readily available in a clinic setting. Current imaging of the oropharynx is performed using a light source and tongue depressors. For better assessment of the inferior pole of the tonsils and tongue base flexible laryngoscopes are required which only provide a two dimensional (2D) rendering. As a result, clinical diagnosis is generally subjective in tonsillar hypertrophy where current physical examination has limitations. In this report, we designed a hand held portable oral camera with 3D imaging capability to reconstruct the anatomy of the oropharynx in tonsillar hypertrophy where the tonsils get enlarged and can lead to increased airway resistance. We were able to precisely reconstruct the 3D shape of the tonsils and from that estimate airway obstruction percentage and volume of the tonsils in 3D printed realistic models. Our results correlate well with Brodsky's classification of tonsillar hypertrophy as well as intraoperative volume estimations.

  View details for DOI 10.1364/BOE.7.001445

  View details for Web of Science ID 000373778900030

  View details for PubMedID 27446667

• A short-wave infrared otoscope for middle ear disease diagnostics PHOTONIC THERAPEUTICS AND DIAGNOSTICS XII Carr, J. A., Valdez, T. A., Bruns, O. T., Bawendi, M. G. 2016; 9689

  View details for DOI 10.1117/12.2209719

  View details for Web of Science ID 000377396200066

• Discerning the differential molecular pathology of proliferative middle ear lesions using Raman spectroscopy SCIENTIFIC REPORTS Pandey, R., Paidi, S. K., Kang, J. W., Spegazzini, N., Dasari, R. R., Valdez, T. A., Barman, I. 2015; 5

  Abstract

  Despite its widespread prevalence, middle ear pathology, especially the development of proliferative lesions, remains largely unexplored and poorly understood. Diagnostic evaluation is still predicated upon a high index of clinical suspicion on otoscopic examination of gross morphologic features. We report the first technique that has the potential to non-invasively identify two key lesions, namely cholesteatoma and myringosclerosis, by providing real-time information of differentially expressed molecules. In addition to revealing signatures consistent with the known pathobiology of these lesions, our observations provide the first evidence of the presence of carbonate- and silicate-substitutions in the calcium phosphate plaques found in myringosclerosis. Collectively, these results demonstrate the potential of Raman spectroscopy to not only provide new understanding of the etiology of these conditions by defining objective molecular markers but also aid in margin assessment to improve surgical outcome.

  View details for DOI 10.1038/srep13305

  View details for Web of Science ID 000359775900001

  View details for PubMedID 26289566

• Nasal vestibulitis due to targeted therapies in cancer patients SUPPORTIVE CARE IN CANCER Ruiz, J. N., Belum, V. R., Boers-Doets, C. B., Kamboj, M., Babady, N. E., Tang, Y., Valdez, T. A., Lacouture, M. E. 2015; 23 (8): 2391-2398

  Abstract

  Cancer patients treated with targeted therapies (e.g., epidermal growth factor receptor inhibitors) are susceptible to dermatologic adverse events (AEs) including secondary skin infections. Whereas infections such as paronychia and cellulitis have been reported, nasal vestibulitis (NV) has not been described with the use of these agents. The aim of our study was to characterize NV in cancer patients treated with targeted therapies.We utilized a retrospective chart review of cancer patients who had been referred to dermatology and were diagnosed with NV. We recorded data including demographics, referral reason, underlying malignancy, targeted anticancer regimen, NV treatment, and nasal bacterial culture results.One Hundred Fifteen patients were included in the analysis, of which 13 % experienced multiple NV episodes. Skin rash was the most common reason (90 %) for a dermatology referral. The most common underlying malignancies were lung (43 %), breast (19 %), and colorectal (10 %) cancer. Sixty-eight percent of patients had been treated with an EGFRI-based regimen. Nasal cultures were obtained in 60 % of episodes, of which 94 % were positive for one or more organisms. Staphylococcus aureus was the most commonly isolated organism [methicillin-sensitive S. aureus 43 %; methicillin-resistant S. aureus 3 %].We report the incidence and characteristics of an unreported, yet frequent dermatologic condition in cancer patients treated with targeted therapies. These findings provide the basis for additional studies to describe the incidence, treatment, and consequences of this event. A better understanding of NV would mitigate its impact on patients' quality of life and risk for additional dermatologic AEs.

  View details for DOI 10.1007/s00520-014-2580-x

  View details for Web of Science ID 000356968100026

  View details for PubMedID 25876156

• Detecting tympanostomy tubes from otoscopic images via offline and online training COMPUTERS IN BIOLOGY AND MEDICINE Wang, X., Valdez, T. A., Bi, J. 2015; 61: 107-118

  Abstract

  Tympanostomy tube placement has been commonly used nowadays as a surgical treatment for otitis media. Following the placement, regular scheduled follow-ups for checking the status of the tympanostomy tubes are important during the treatment. The complexity of performing the follow up care mainly lies on identifying the presence and patency of the tympanostomy tube. An automated tube detection program will largely reduce the care costs and enhance the clinical efficiency of the ear nose and throat specialists and general practitioners. In this paper, we develop a computer vision system that is able to automatically detect a tympanostomy tube in an otoscopic image of the ear drum. The system comprises an offline classifier training process followed by a real-time refinement stage performed at the point of care. The offline training process constructs a three-layer cascaded classifier with each layer reflecting specific characteristics of the tube. The real-time refinement process enables the end users to interact and adjust the system over time based on their otoscopic images and patient care. The support vector machine (SVM) algorithm has been applied to train all of the classifiers. Empirical evaluation of the proposed system on both high quality hospital images and low quality internet images demonstrates the effectiveness of the system. The offline classifier trained using 215 images could achieve a 90% accuracy in terms of classifying otoscopic images with and without a tympanostomy tube, and then the real-time refinement process could improve the classification accuracy by 3-5% based on additional 20 images.

  View details for DOI 10.1016/j.compbiomed.2015.03.025

  View details for Web of Science ID 000356108400011

  View details for PubMedID 25889718

• Multi-color reflectance imaging of middle ear pathology in vivo ANALYTICAL AND BIOANALYTICAL CHEMISTRY Valdez, T. A., Spegazzini, N., Pandey, R., Longo, K., Grindle, C., Peterson, D., Barman, I. 2015; 407 (12): 3277-3283

  Abstract

  Otoscopic examination using white-light illumination has remained virtually unchanged for well over a century. However, the limited contrast of white-light otoscopy constrains the ability to make accurate assessment of middle ear pathology and is subject to significant observer variability. Here, we employ a modified otoscope with multi-color imaging capabilities for superior characterization of the middle ear constituents in vivo and for enhanced diagnosis of acute otitis media and cholesteatoma. In this pilot study, five patients undergoing surgery for tympanostomy tube placement and congenital cholesteatoma excision were imaged using the custom-designed multi-color video-rate reflectance imaging system. We show that the multi-color imaging approach offers an increase in image contrast, thereby enabling clear visualization of the middle ear constituents, especially of the tympanic membrane vascularity. Differential absorption at the multiple wavelengths provides a measure of biochemical and morphological information, and the rapid acquisition and analysis of these images aids in objective evaluation of the middle ear pathology. Our pilot study shows the potential of using label-free narrow-band reflectance imaging to differentiate middle ear pathological conditions from normal middle ear. This technique can aid in obtaining objective and reproducible diagnoses as well as provide assistance in guiding excisional procedures.

  View details for DOI 10.1007/s00216-015-8580-y

  View details for Web of Science ID 000352640300005

  View details for PubMedID 25753015

• Current Trends in Perioperative Antibiotic Use: A Survey of Otolaryngologists OTOLARYNGOLOGY-HEAD AND NECK SURGERY Valdez, T. A., Marvin, K., Bennett, N. J., Lerer, T., Nolder, A. R., Buchinsky, F. J. 2015; 152 (1): 63-66

  Abstract

  This study describes the patterns of perioperative antimicrobial use by otolaryngologists during common otolaryngologic surgical procedures. Through the American Academy of Otolaryngology--Head and Neck Surgery Infectious Diseases Committee, a survey was developed to assess the current practice patterns regarding the use of perioperative antibiotics in otolaryngology. A total of 6903 surveys were sent out; 458 were fully or partially completed, and a total of 442 responses were included in the final analysis. Most physicians reported routinely prescribing antibiotics either preoperatively or postoperatively for 12 of the 17 procedures included in the questionnaire despite providers agreeing that there is not enough evidence to support their use. The most common procedure for which antibiotics were prescribed was laryngectomy (91.1%). Antibiotic use is a common practice during the perioperative period for otolaryngologic procedures; however, there is a discrepancy between utilization and evidence of benefit.

  View details for DOI 10.1177/0194599814554551

  View details for Web of Science ID 000347066300008

  View details for PubMedID 25305267

• Development of the Connecticut Airway Risk Evaluation (CARE) System to Improve Handoff Communication in Pediatric Patients With Tracheotomy JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY Hughes, A. L., Murray, N., Valdez, T. A., Kelly, R., Kavanagh, K. 2014; 140 (1): 29-33

  Abstract

  National attention has focused on the importance of handoffs in medicine. Our practice during airway patient handoffs is to communicate a patient-specific emergency plan for airway reestablishment; patients who are not intubatable by standard means are at higher risk for failure. There is currently no standard classification system describing airway risk in tracheotomized patients.To introduce and assess the interrater reliability of a simple airway risk classification system, the Connecticut Airway Risk Evaluation (CARE) system.We created a novel classification system, the CARE system, based on ease of intubation and the need for ventilation: group 1, easily intubatable; group 2, intubatable with special equipment and/or maneuvers; group 3, not intubatable. A "v" was appended to any group number to indicate the need for mechanical ventilation. We performed a retrospective medical chart review of patients aged 0 to 18 years who were undergoing tracheotomy at our tertiary care pediatric hospital between January 2000 and April 2011. INTERVENTIONS Each patient's medical history, including airway disease and means of intubation, was reviewed by 4 raters. Patient airways were separately rated as CARE groups 1, 2, or 3, each group with or without a v appended, as appropriate, based on the available information.After the patients were assigned to an airway group by each of the 4 raters, the interrater reliability was calculated to determine the ease of use of the rating system.We identified complete data for 155 of 169 patients (92%), resulting in a total of 620 ratings. Based on the patient's ease of intubation, raters categorized tracheotomized patients into group 1 (70%, 432 of 620); group 2 (25%, 157 of 620); or group 3 (5%, 29 of 620), each with a v appended if appropriate. The interrater reliability was κ = 0.95.We propose an airway risk classification system for tracheotomized patients, CARE, that has high interrater reliability and is easy to use and interpret. As medical providers and national organizations place more focus on improvements in interprovider communication, the creation of an airway handoff tool is integral to improving patient safety and airway management strategies following tracheotomy complications.

  View details for DOI 10.1001/jamaoto.2013.5550

  View details for Web of Science ID 000331369700004

• Bi modal Approach Using Spectroscopy and Digital Imaging to assist Otitis Media Diagnosis 2014 40TH ANNUAL NORTHEAST BIOENGINEERING CONFERENCE (NEBEC) Longo, K., Peterson, D., Valdez, T. A. 2014

  View details for Web of Science ID 000364054600159

• Development of the Connecticut Airway Risk Evaluation (CARE) system to improve handoff communication in pediatric patients with tracheotomy. JAMA otolaryngology-- head & neck surgery Lawrason Hughes, A., Murray, N., Valdez, T. A., Kelly, R., Kavanagh, K. 2014; 140 (1): 29-33

  Abstract

  National attention has focused on the importance of handoffs in medicine. Our practice during airway patient handoffs is to communicate a patient-specific emergency plan for airway reestablishment; patients who are not intubatable by standard means are at higher risk for failure. There is currently no standard classification system describing airway risk in tracheotomized patients.To introduce and assess the interrater reliability of a simple airway risk classification system, the Connecticut Airway Risk Evaluation (CARE) system.We created a novel classification system, the CARE system, based on ease of intubation and the need for ventilation: group 1, easily intubatable; group 2, intubatable with special equipment and/or maneuvers; group 3, not intubatable. A "v" was appended to any group number to indicate the need for mechanical ventilation. We performed a retrospective medical chart review of patients aged 0 to 18 years who were undergoing tracheotomy at our tertiary care pediatric hospital between January 2000 and April 2011. INTERVENTIONS Each patient's medical history, including airway disease and means of intubation, was reviewed by 4 raters. Patient airways were separately rated as CARE groups 1, 2, or 3, each group with or without a v appended, as appropriate, based on the available information.After the patients were assigned to an airway group by each of the 4 raters, the interrater reliability was calculated to determine the ease of use of the rating system.We identified complete data for 155 of 169 patients (92%), resulting in a total of 620 ratings. Based on the patient's ease of intubation, raters categorized tracheotomized patients into group 1 (70%, 432 of 620); group 2 (25%, 157 of 620); or group 3 (5%, 29 of 620), each with a v appended if appropriate. The interrater reliability was κ = 0.95.We propose an airway risk classification system for tracheotomized patients, CARE, that has high interrater reliability and is easy to use and interpret. As medical providers and national organizations place more focus on improvements in interprovider communication, the creation of an airway handoff tool is integral to improving patient safety and airway management strategies following tracheotomy complications.

  View details for DOI 10.1001/jamaoto.2013.5550

  View details for PubMedID 24203121

• Phoma and Acremonium invasive fungal rhinosinusitis in congenital acute lymphocytic leukemia and literature review INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Roehm, C. E., Salazar, J. C., Hagstrom, N., Valdez, T. A. 2012; 76 (10): 1387-1391

  Abstract

  Invasive rhinocerebral fungal infections are a difficult and often fatal problem in children with hematologic malignancies, with increasing reports of rare pathogens. We describe a case of congenital acute lymphoblastic leukemia (ALL) and invasive fungal rhinosinusitis involving Acremonium and Phoma species, not previously reported in invasive pediatric fungal rhinosinusitis, and review all published cases of human Phoma infections.A literature and institutional review for Phoma spp. was completed including patient demographics, infection site, immune status, treatment and outcome.A female neonate with acute lymphoblastic leukemia presented with hyperleukocytosis and advanced invasive Phoma and Acremonium spp. rhinosinusitis. Despite aggressive medical and surgical therapy, the disease progressed to a rhinocerebral infection with a fatal outcome. Twenty cases of Phoma spp. were found in a complete literature search, including 6 females and 14 males from 18 months to 77 years old. Infections were superficial in fifteen patients and involved deeper tissue in five patients, with sites including cutaneous, subcutaneous and deep tissue sites (eye, lung, extremity deep tissue compartments).This case highlights the risks and grave prognosis of fulminant invasive fungal rhinosinusitis in the context of congenital leukemia, and the potential for rare fungal species in neonates with immunosuppression.

  View details for DOI 10.1016/j.ijporl.2012.06.026

  View details for Web of Science ID 000310048800001

  View details for PubMedID 22818128

• Bacterial Tracheitis A Varied Entity PEDIATRIC EMERGENCY CARE Miranda, A. D., Valdez, T. A., Pereira, K. D. 2011; 27 (10): 950-953

  Abstract

  The objective of the study was to highlight the different presentations of bacterial tracheitis (BT), a potential life-threatening cause of airway obstruction in children.Case series.A review of medical records of 4 cases of BT who presented with differing signs and symptoms was performed.Clinical manifestations of 4 patients with BT are presented with corresponding endoscopic appearances of the airway. Two patients were afebrile and nontoxic, and 2 had an elevated white cell count. Three had different degrees of stridor. One had a respiratory arrest. Cultures grew Staphylococcus aureus in 2 and Moraxella catarrhalis in 1 and were mixed in 1 patient. None required intubation. All were successfully treated with antibiotics and bronchoscopic debridement of the membranes.Bacterial tracheitis needs a high index of suspicion because of its varied presentations. Certain forms have less severe clinical manifestations. These forms also require aggressive management as they can result in airway obstruction from membranes and edema.

  View details for DOI 10.1097/PEC.0b013e3182309d45

  View details for Web of Science ID 000295873400013

  View details for PubMedID 21975496

• Evaluation of Pediatric Sensorineural Hearing Loss: A Survey of Pediatric Otolaryngologists ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY Rutherford, K. D., Lerer, T. S., Schoem, S. R., Valdez, T. A. 2011; 120 (10): 674-681

  Abstract

  We sought to determine the trends in the evaluation of pediatric patients with sensorineural hearing loss (SNHL) and to determine evaluation patterns based on respondents' demographic data.All members of the American Society of Pediatric Otolaryngology were invited to voluntarily and anonymously complete an online survey. The survey was available from September 2009 to January 2010 and addressed demographic data and tests obtained in evaluating new pediatric patients with SNHL at different age points and with different degrees of hearing loss.The response rate was 22.9% (79 of 345). For all ages and all types of SNHL, the most common consultations were genetics (26% to 76%) and ophthalmology (31% to 66%) consultations. Computed tomography of the temporal bones (49% to 66%), genetic testing (25% to 68%), and electrocardiography (13% to 43%) were the most commonly performed tests. Although there was no consistent difference in practice patterns by gender or years of practice, there were differences in the use of thyroid function tests, TORCH titers, and autoimmune studies by hospital affiliation.Type of SNHL and age are factors in the evaluation of pediatric patients with SNHL. Additionally, evaluation patterns differ according to region and hospital affiliation. The results of this study may provide guidance for otolaryngologists in making information-based and cost-effective evaluations.

  View details for Web of Science ID 000296209100008

  View details for PubMedID 22097154

• Preliminary Findings on the Effects of Topical Photoactivated Antimicrobial Methyl-delta-Aminolevulinic Acid on Murine Hearing Thresholds OTOLARYNGOLOGY-HEAD AND NECK SURGERY Roehm, C. E., Valdez, T. A., Parham, K. 2011; 144 (6): 959-961

  Abstract

  This study evaluates the ototoxicity of a potential novel ototopical antimicrobial, photoactivated methyl-δ-aminolevulinic acid (M-ALA). Ten CBA/J mice received intratympanic injections of 10 mM M-ALA and 640 nm light source illumination for 7 days, with contralateral ears receiving saline. Auditory-evoked brainstem response (ABR) thresholds (8, 16, 24, and 32 kHz) were determined preinjection and at 1, 30, and 90 days postinjection. Mean ABR thresholds were similar after intratympanic administration of M-ALA and saline (F ratio, 0.001; P = .971). ABR thresholds temporarily increased in both groups (F ratio, 28.52; P = .00) at day 1 postinjection of intratympanic treatments but returned to baseline at day 30 and 90. This temporary elevation was associated with tympanic membrane perforations and granulation tissue at the injection sites, which resolved by day 30 posttreatment. The preliminary findings indicate that intratympanic application of M-ALA with light activation over a 7-day course in a murine model does not produce measurable ototoxicity and is well tolerated.

  View details for DOI 10.1177/0194599811399850

  View details for Web of Science ID 000293998800025

  View details for PubMedID 21493320

• Postcricoid Vascular Lesions: Histopathological and Immunohistochemical Diagnosis LARYNGOSCOPE Roehm, C. E., Chelius, D. C., Larrier, D., Hicks, M. J., Albright, J. T., Valdez, T. A. 2011; 121 (2): 397-403

  Abstract

  Postcricoid vascular lesions are a rare cause of dysphagia and stridor in the pediatric population. Currently, there is no clear consensus on what type of vascular lesions are common in the postcricoid area because adequate histological or immunohistochemistry studies are lacking. This study aimed to describe the histology and immunohistochemistry of postcricoid masses in our institutions' experience, and consolidate available data on the symptoms, management, and histology of these unusual malformations with a comprehensive literature review.Retrospective patient and literature review.A retrospective review of patients with postcricoid vascular lesions was performed at two pediatric tertiary care institutions. Histology and immunohistochemistry studies were performed in patients undergoing a lesion biopsy. A complete literature review of the English language was completed for cases involving vascular lesions of the postcricoid area.Four patients were identified in our study with postcricoid vascular lesions. All patients presented with symptoms of dysphagia and intermittent stridor. Histology and immunohistochemistry studies were performed in three patients. GLUT-1 was negative in all three patients, and CD34 was positive in all patients tested. Lewis Y antigen was performed in one patient and was negative. A description of 19 cases reported in the English literature is included.Patients with postcricoid vascular lesions usually present with mild to moderate feeding difficulties, and stridor or dyspnea with agitation. Histopathology and immunohistochemistry results suggest that postcricoid vascular lesions may often represent congenital vascular malformations instead of infantile hemangiomas.

  View details for DOI 10.1002/lary.21243

  View details for Web of Science ID 000287006400031

  View details for PubMedID 21271596

• Enhanced Video Images for Tympanic Membrane Characterization 2011 ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY (EMBC) Cheng, L., Liu, J., Roehm, C. E., Valdez, T. A. 2011: 4002-4005

  Abstract

  The objective of this article is to introduce portable devices capable of providing video images of the tympanic membrane and tympanic cavity of the ear. Specifically, digital video otoscopy is introduced as an effective platform for tympanic membrane characterization. In addition, we show how digital image enhancement and segmentation processing techniques can be applied to the acquired images, which could provide more visual detail and objective clinical interpretation.

  View details for Web of Science ID 000298810003086

  View details for PubMedID 22255217

• Microbiology of Third and Fourth Branchial Pouch Cysts LARYNGOSCOPE Pahlavan, S., Haque, W., Pereira, K., Larrier, D., Valdez, T. A. 2010; 120 (3): 458-462

  Abstract

  To identify the most common pathogens involved in infections of third and fourth branchial pouch cysts. Third and fourth branchial pouch cyst infections are an uncommon cause of anterior neck abscesses often confused with other entities, such as thyroglossal duct cysts and thyroid abscesses leading to misdiagnosis, recurrence, and increased morbidity related to a delay in diagnosis and appropriate treatment.Retrospective chart and literature review.Retrospective chart review case series of patients presenting to the Bobby R. Alford Department of Otolaryngology at Texas Children's Hospital from July 2004 to July 2008 with third and fourth branchial pouch cysts.A total of 11 patients were identified. All patients had left-sided lesions. Eikenella corrodens was found in 60% of cultures and was the most common organism identified in our patient group. Furthermore, 56% of the organisms isolated were anaerobic. All organisms with the exception of Staphylococcus aureus were identified as oral cavity flora.Third and fourth branchial pouch cysts provide a communication between the neck and the oral cavity through pyriform sinus tracts. The presence of oral cavity flora in a left anterior neck abscess should raise the suspicion of a branchial pouch anomaly, and subsequently alter therapeutic management.

  View details for DOI 10.1002/lary.20724

  View details for Web of Science ID 000275224200004

  View details for PubMedID 20014149

• Kaposiform hemangioendothelioma (with Kasabach Merritt syndrome) of the head and neck: Case report and review of the literature INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Mukerji, S. S., Osborn, A. J., Roberts, J., Valdez, T. A. 2009; 73 (10): 1474-1476

  Abstract

  An infant initially diagnosed with a parotid hemangioma presented with stridor and thrombocytopenia. Diagnosis of Kaposiform hemangioendothelioma was confirmed with biopsy. The child succumbed to multi-system organ failure related to consumptive coagulopathy despite aggressive medical management. Kaposiform hemangioendothelioma is a rare head and neck tumor that may be mistaken for a hemangioma on preliminary diagnosis, which may lead to increased morbidity and mortality especially in the setting of Kasabach-Merritt phenomenon. A platelet count may provide an early and important clue to the possibility of coagulopathy; prompting physicians to look for a diagnosis other than a simple hemangioma.

  View details for DOI 10.1016/j.ijporl.2009.06.019

  View details for Web of Science ID 000270252100034

  View details for PubMedID 19643504

• Sensorineural hearing loss in patients with inflammatory bowel disease AMERICAN JOURNAL OF OTOLARYNGOLOGY Karmody, C. S., Valdez, T. A., Desai, U., Blevins, N. H. 2009; 30 (3): 166-170

  Abstract

  The study aimed to discuss the association between sensorineural hearing loss (SNHL) and inflammatory bowel disease (IBD).We reviewed cases of patients with known IBD seen in an otolaryngology practice with documentation of all otologic data including age of onset, family history of otologic problems, exposure to noise, audiometric findings, and so on.Of 38 patients with a history of IBD, 22 had documented SNHL. Nineteen of these had no other identifiable etiology for their inner ear dysfunction. Fourteen of these patients had a diagnosis of ulcerative colitis and 5 had Crohn disease. Sixteen patients had bilateral SNHL, and 3 patients had unilateral SNHL. Only one patient had a lasting response of SNHL to medical treatment.This review suggests that SNHL is an extraintestinal association of IBD. As IBD is considered to be a local or systemic immunopathy, the associated SNHL might also be an expression of systemic immune dysfunction.

  View details for DOI 10.1016/j.amjoto.2008.04.009

  View details for Web of Science ID 000266175400006

  View details for PubMedID 19410121

• Pneumococcal mastoiditis in children and the emergence of multidrug-resistant serotype 19A isolates PEDIATRICS Ongkasuwan, J., Valdez, T. A., Hulten, K. G., Mason, E. O., Kaplan, S. L. 2008; 122 (1): 34-39

  Abstract

  We review the impact of pneumococcal conjugate vaccine on pneumococcal mastoiditis in children at Texas Children's Hospital.The medical charts (including the number of pneumococcal conjugate vaccine doses) for children with pneumococcal mastoiditis treated at Texas Children's Hospital between January 1995 and June 2007 were reviewed retrospectively. Isolates were serotyped with the capsular swelling method. Pulsed-field gel electrophoresis was performed on the 19A isolates and multilocus sequence typing on selected 19A clones.Forty-one pneumococcal mastoiditis cases were identified, and 19A (n = 19) was the most common serotype. Before the introduction of pneumococcal conjugate vaccine (from 1995 to December 1999), 0 of 12 cases were 19A. Between April 2000 and October 2006, 15 cases of pneumococcal mastoiditis occurred, and 5 were 19A. Fourteen cases of pneumococcal mastoiditis occurred between November 2006 and June 2007, all of which were 19A. Mastoiditis caused by 19A isolates was more likely to present with subperiosteal abscess and was more likely to need intraoperative mastoidectomy than was mastoiditis caused by non-19A isolates. Multidrug resistance was also common among the 19A isolates; 13 (68%) of the 19A isolates were resistant to all antibiotics tested routinely. Pulsed-field gel electrophoresis analysis placed 14 (74%) of the 19 serotype 19A isolates into a highly related group; 12 isolates were classified as closely related, and 2 were possibly related. Multilocus sequence typing analysis placed the pulsed-field gel electrophoresis cluster isolates into clonal complex 271 (sequence types 320 and 1451).At Texas Children's Hospital, 19A has become the predominant serotype causing pneumococcal mastoiditis, partly related to the emergence of multidrug-resistant clonal complex 271 strains. Subperiosteal abscesses and the need for mastoidectomy were more common in children with mastoiditis caused by serotype 19A isolates, compared with isolates of other serotypes.

  View details for DOI 10.1542/peds.2007-2703

  View details for Web of Science ID 000257271200006

  View details for PubMedID 18595984

• Airway foreign bodies and brain abscesses: Report of two cases and review of the literature INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Roberts, J., Bartlett, A. H., Giannoni, C. M., Valdez, T. A. 2008; 72 (2): 265-269

  Abstract

  We report two cases of intracranial abscess in pediatric patients secondary to aspirated foreign bodies. Although foreign bodies are a significant cause of morbidity and mortality in the pediatric population, only four previous cases have been reported that resulted in a brain abscess. Our patients presented with neurological symptoms, and both were found to have a sharp foreign body in the bronchus. Both had brain abscesses caused by bacteria that normally colonize the aerodigestive tract with no other source of bacterial foci. When respiratory flora are isolated from brain abscesses in the absence of other possible sources, intrabronchial foreign body should be considered in evaluation of the etiology.

  View details for DOI 10.1016/j.ijporl.2007.10.006

  View details for Web of Science ID 000253088000019

  View details for PubMedID 18031834

• Recurrent fetal rhabdomyoma of the head and neck INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Valdez, T. A., Desai, U., Volk, M. S. 2006; 70 (6): 1115-1118

  Abstract

  We present a case of a congenital fetal rhabdomyoma which recurred after surgical excision. A review of the patient's chart, imaging studies, operative reports and histologic findings were conducted. A congenital fetal rhabdomyoma involving the head and neck region diagnosed prenatally by ultrasound and MRI was surgically excised without complications. The patient presented with recurrence of the tumor fourteen months after the initial surgery. This case report is supplemented with a review of the relevant literature on congenital fetal rhabdomyoma. This is the fifth documented case of recurrence of a fetal rhabdomyoma. Extracardiac rhabdomyomas are extremely rare benign tumors. Complete excision of these lesions is curative with only a handful of recurrences documented in the literature. Close follow up and a complete workup to rule out rhabdomyosarcoma is warranted in all cases of recurrence.

  View details for DOI 10.1016/j.ijporl.2005.10.024

  View details for Web of Science ID 000237864100025

  View details for PubMedID 16406074

• Early laryngeal inhalation injury and its correlation with late sequelae LARYNGOSCOPE Valdez, T. A., Desai, U., Ruhl, C. M., Nigri, P. T. 2006; 116 (2): 283-287

  Abstract

  Inhalation injury can permanently alter normal laryngeal function. The aim of this study was to examine the early changes in voice, swallowing, and breathing in laryngeal inhalation injuries.This was a prospective analysis of nine patients with inhalation injuries at a tertiary care institution.Laryngeal function of patients admitted for inhalation injury requiring intubation was documented using videostroboscopy and swallowing evaluation by the speech pathology service. Bronchoscopy was used to classify the degree of inhalation injury. Association among total body surface area, facial burns, severity of laryngotracheal injuries, and loss of function was attempted.All three patients with severe tracheal inhalation injury presented persistent hoarseness at 1-year follow up with abnormal videostroboscopy findings. No association was found between inhalation injury and total body surface area burned. None of the patients in this series presented permanent swallowing dysfunction.The otolaryngologist plays an important role in the initial and long-term management of inhalation injuries. Inhalation injuries should be managed in a multidisciplinary fashion. There may be a correlation between the degree of tracheal injury and laryngeal injury and hoarseness.

  View details for DOI 10.1097/01.mlg.0000197932.09386.0e

  View details for Web of Science ID 000235566100023

  View details for PubMedID 16467720

• Spectroscopic detection and evaluation of morphologic and biochemical changes in early human oral carcinoma CANCER Muller, M. G., Valdez, T. A., Georgakoudi, I., Backman, V., Fuentes, C., Kabani, S., Laver, N., Wang, Z. M., BOONE, C. W., Dasari, R. R., Shapshay, S. M., Feld, M. S. 2003; 97 (7): 1681-1692

  Abstract

  Understanding the development and progression of head and neck squamous cell carcinoma is key in the quest for the early diagnosis and prevention of this type of malignancy. The current study correlated early biochemical and histologic changes in oral tissue with spectral features in fluorescence, reflectance, and light scattering spectra acquired in vivo to diagnose early stages of oral malignancies.A total of 91 tissue sites from 15 patients with varying degrees of malignancy (normal, dysplastic, and cancerous sites) and 8 healthy volunteers were analyzed with 3 spectroscopic techniques. Direct biochemical information regarding oral tissue native fluorophores was obtained with intrinsic fluorescence spectroscopy by fitting a linear combination of collagen and the reduced form of nicotinamide adenine dinucleotide (NADH) fluorescence spectra to the intrinsic tissue fluorescence spectra excited with 337 nanometer (nm) and 358-nm laser light. Diffuse reflectance spectroscopy was used to provide information regarding tissue absorption and structure, such as hemoglobin concentration and stroma density, by measuring the wavelength-dependent absorption and scattering coefficients. By subtracting the diffusely reflected component from the measured reflectance, light scattering spectroscopy (LSS) information resulting from single backscattering from epithelial cell nuclei was obtained. LSS provides information concerning the size distribution of cell nuclei.These optically extracted tissue parameters provide biochemical or structural information in vivo without the need for tissue excision, and can be used to diagnose tissue abnormalities. By combining the information provided by the three techniques, a method known as trimodal spectroscopy, a sensitivity and specificity of 96% and 96%, respectively, in distinguishing cancerous/dysplastic (mild, moderate, and severe) from normal tissue was achieved. In addition, the authors were able to distinguish dysplastic from cancerous tissue with a sensitivity of 64% and a specificity of 90%.The results of the current study demonstrated that Trimodal spectroscopy is a highly sensitive and specific technique with which to diagnose tissue abnormalities.

  View details for DOI 10.1002/cncr.11255

  View details for Web of Science ID 000181816600012

  View details for PubMedID 12655525

• Idiopathic subglottic stenosis revisited ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY Valdez, T. A., Shapshay, S. M. 2002; 111 (8): 690-695

  Abstract

  Idiopathic subglottic stenosis (ISS) is a rare inflammatory process of unknown cause, usually limited to the subglottic region and the first 2 tracheal rings. We performed a retrospective analysis of our experience with a series of patients with this condition. The study involved retrospective review of the records of patients with ISS. A series of criteria that included patient clinical history, laboratory tests, flexible nasolaryngoscopic examination, and biopsies were used to establish a diagnosis. Symptoms, treatment, and outcome were examined. A total of 16 patients were identified; 14 were female (87.5%), and 2 were male. The mean follow-up time was 75.5 months. Fourteen patients required surgical treatment for respiratory compromise. Nine of these cases have been controlled effectively with endoscopic laser techniques. Endoscopic management failed in 5 patients, and 2 patients underwent laryngotracheal resection and reconstruction. Mitomycin-C was used in 6 patients as an adjuvant to endoscopic laser surgery. Patients in whom endoscopic treatment failed were noted to have thicker (>1 cm) and more complex stenoses. The diagnosis of ISS is a diagnosis of exclusion. A complete workup of the patient must be performed to rule out other causes of stenosis. Endoscopic laser surgery is a valid initial approach for thinner, noncomplicated lesions. Patients with thicker, complex lesions in whom endoscopic treatment fails are best managed with laryngotracheal resection and reconstruction. However, adjuvant use of mitomycin-C may prove beneficial in the treatment of these patients. Estrogen may play a role in the pathogenesis of ISS by altering the wound healing response.

  View details for Web of Science ID 000177409700006

  View details for PubMedID 12184589

• Bronchoscopic management of benign stenosis. Chest surgery clinics of North America Shapshay, S. M., Valdez, T. A. 2001; 11 (4): 749-68

  Abstract

  In summary, the use of laser technology in the airway for the treatment of benign lesions has become a standard therapeutic modality for the airway endoscopist. It is extremely important that endoscopists be well acquainted with the laser soft tissue interactions of the laser being used and the safety precautions associated with each individual wavelength. They should be conversant with the indications and contraindications and have the ability to use adjuvant therapeutic modalities, such as stents and medications. As usual, patient selection is one of the key factors related to successful management.

  View details for PubMedID 11780294

• Pulsed-dye laser and retinoic acid delay progression of oral squamous cell carcinoma: A murine model LARYNGOSCOPE Shah, R. K., Valdez, T. A., Wang, Z., Shapshay, S. M. 2001; 111 (7): 1203-1208

  Abstract

  This study examined the role of the pulsed-dye laser (PDL) at 585 nm coupled with retinoic acid at therapeutic (5.0 mg/kg) and nontherapeutic (0.5 mg/kg) doses to delay the progression of cancer with a two-hit approach. The existing vasculature is selectively targeted by the laser, whereas retinoic acid inhibits future angiogenesis.Randomized, prospective study in a murine model.Twenty-five athymic nude mice were inoculated with oral squamous cell cancers on six flank sites and randomly divided into five groups: 1) control subjects, 2) treatment with 0.5 mg/kg retinoic acid (RA 0.5), 3) treatment with 5.0 mg/kg retinoic acid (RA 5.0), 4) treatment with RA 0.5 + PDL, and 5) treatment with RA 5.0 + PDL. The PDL groups received irradiation after inoculation. The retinoic acid was administered daily. The tumors were counted and measured for 14 days.The control group developed visible tumors in 50% of the inoculation sites at 3 days compared with 3 days (RA 0.5) and 4 days (RA 5.0) for the retinoic acid groups and 9 days (RA 0.5 + PDL) and 10 days (RA 5.0 + PDL) for the laser treatment groups. There was no tumor growth until day 7 in the RA 5.0 + PDL group. The tumor volume was statistically different between the treatment groups.This study demonstrated the superiority of a single treatment with the PDL coupled with retinoic acid to delay the progression of cancer when compared with treatment with retinoic acid alone, thus introducing a novel strategy in cancer control.

  View details for Web of Science ID 000169764500012

  View details for PubMedID 11568542

• Anterior window laryngoplasty: A new anatomic approach for posterior glottic and subglottic stenosis ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY Valdez, T. A., Wang, Z., Schumann, R., Shapshay, M. 2001; 110 (6): 519-523

  Abstract

  This study explores the feasibility of an anterior thyroid window as a new approach for posterior glottic stenosis. An anterior window was made on the thyroid cartilage of human cadaver larynges, with its superior edge below the level of the vocal cords and an inferior pedicle composed of the inferior border of the thyroid cartilage attached to the cricothyroid membrane, which was left intact. By obtaining direct exposure of the posterior glottis and cricoarytenoid joints, mucosal graft suturing and exploration of the joints were easily achieved with an operating microscope. This study demonstrates the anatomic feasibility of an anterior window laryngoplasty as an alternative approach to treating posterior glottic stenosis while preserving the cartilage framework and avoiding the anterior commissure. This technique may improve endolaryngeal manipulation by providing a closer and more direct exposure than do endoscopic techniques, and by having fewer possible complications than traditional open techniques.

  View details for Web of Science ID 000169238600005

  View details for PubMedID 11407842

• A new loser treatment for vocal cord papilloma-585-nm pulsed dye OTOLARYNGOLOGY-HEAD AND NECK SURGERY Valdez, T. A., McMillan, K., Shapshay, S. M. 2001; 124 (4): 421-425

  Abstract

  Microvascular targeting with the 585- nm pulsed dye laser (PDL) may provide a new form of therapy to control symptoms caused by recurrent respiratory papillomatosis (RRP).Ten patients with RRP underwent 13 procedures under general anesthesia with the 585-nm PDL. A micromanipulator (11 procedures) and a flexible nasolaryngoscope (2 procedures) were used to deliver the laser pulses. Patients were followed postoperatively according to protocol.Clinical examination revealed regression of papillomas in all patients. Seven patients had complete regression after PDL surgery, and 2 patients had partial response to treatment. One patient was lost to follow-up. No complications were present during this prospective nonrandomized pilot study.Patients treated with PDL experienced regression of their papillomas. PDL may provide patients with RRP with an alternative treatment without the risks associated with CO(2) laser surgery. This procedure also has potential to be delivered on an outpatient basis with flexible fiberoptic laryngoscopes.

  View details for Web of Science ID 000168031100012

  View details for PubMedID 11283500

• Pulsed dye laser treatment of laryngeal papillomas BRONCHOLOGY AND BRONCHOESOPHAGOLOGY: STATE OF THE ART Shapshay, S. M., Valdez, T. A. 2001; 1217: 90-94

  View details for Web of Science ID 000173940100015

• Detection of preinvasive cancer cells NATURE Backman, Wallace, M. B., Perelman, L. T., Arendt, J. T., Gurjar, R., Muller, M. G., Zhang, Q., Zonios, G., Kline, E., McGillican, T., Shapshay, S., Valdez, T., Badizadegan, K., Crawford, J. M., Fitzmaurice, M., Kabani, S., Levin, H. S., Seiler, M., Dasari, R. R., Itzkan, Van Dam, J., Feld, M. S. 2000; 406 (6791): 35-36

  View details for DOI 10.1038/35017638

  View details for Web of Science ID 000087991200032

  View details for PubMedID 10894529

• Light scattering spectroscopy: A new technique for clinical diagnosis of precancerous and cancerous changes in human epithelial tissues Lasers in the Life Sciences Backman, V., Wallace, M., Perelman, L. T., Arendt, J. T., Gurjar, R., Muller, M. G., Zhang, Q., Zonios, G., Kline, E., McGilligan, T., Valdez, T., Van Dam, J., Badizadegan, K., Crawford, J. M., Fitzmaurice, M., Kabani, ., Levin, . S., Seiler, ., Dasari, R. R., Itzkan, I., Feld, M. S. 2000; 9 (4): 255-264