Dr. Zara M. Patel is Director of Endoscopic Skull Base Surgery and an Associate Professor of Otolaryngology and, by courtesy, of Neurosurgery at Stanford. She was born and raised in St. Louis, completed her MD at the Oregon Health and Sciences University in Portland, Oregon and completed her residency training in otolaryngology at Mount Sinai Medical Center in New York, NY. After pursuing fellowship training in rhinology and endoscopic skull base surgery at Stanford University, she was recruited to join the Emory University faculty in Atlanta in 2011. After four years, the rhinology division recruited her back to the West coast to rejoin the department here at Stanford University.

Dr. Patel is an expert in advanced endoscopic sinus and skull base surgery. She treats patients with a wide variety of rhinologic complaints, including chronic sinus infection or inflammation, sinus disease that has failed medical therapy, sinus disease that has failed prior surgical therapy, cerebrospinal fluid leaks, benign and and malignant sinus and skull base tumors, as well as olfactory disorders.

She is immediate past-Chair of the Education Committee and now Member of the Board of Directors for the American Rhinologic Society and has developed a multitude of educational materials for both physicians and patients to help them better understand rhinologic disorders. She is passionate about educating patients to allow them to make the best decisions about their own care, leading to better outcomes.

Dr. Patel has published widely in topics such as avoiding complications in endoscopic sinus surgery, chronic rhinosinusitis in the immunosuppressed patient population, new devices and techniques for endoscopic skull base surgery, and olfactory dysfunction. She continues to perform research in these areas, and is beginning collaborative efforts with neuroscientists and engineers to develop technology that she hopes will eventually help cure patients with olfactory loss.

Clinical Focus

  • Endoscopic Sinus and Skull Base Surgery
  • Chronic Rhinosinusitis
  • Benign and Malignant Sinus and Skull Base Tumors
  • Olfaction and Olfactory Disorders
  • Cerebrospinal Fluid Leaks
  • Sinusitis
  • Nasal Obstruction
  • Epiphora, Orbital Tumors, Orbital decompression
  • Pituitary Surgery
  • Rhinology
  • Otolaryngology

Academic Appointments

Administrative Appointments

  • Director of Endoscopic Skull Base Surgery, Department of Otolaryngology - Head and Neck Surgery (2017 - Present)
  • Director Rhinology Fellowship, Department of Otolaryngology-Head and Neck Surgery, Stanford University (2015 - Present)

Honors & Awards

  • Fellow, American Rhinologic Society (2016)
  • Woodruff Teaching Award, Emory University (2014)
  • Mount Sinai Resident Teaching Award, Mount Sinai Medical School (2010)
  • First Place, New York City Otolaryngology Resident Research Day (2008)
  • Leadership Grant, American Academy of Otolaryngology (2007, 2008)
  • Campbell Scholarhsip, Oregon Health and Sciences University (2004)
  • Inductee, National Medical Honors Society, Alpha Omega Alpha (2004)
  • OHSU Rose Award, Oregon Health and Sciences University (2003)
  • Miller Memorial Fund Scholarship, University of Missouri (2001-2003)
  • Hughes Academic Achievement Award, State of Missouri (2000)
  • Inductee, National Honor Society, Phi Bet Kappa (2000)
  • Inductee, National Honor Society, Phi Eta SIgma (1998)
  • Bright Flight Scholarship, University of Missouri (1997-2001)
  • National Merit Finalist, National Merit Scholarship Corporation (1997)

Boards, Advisory Committees, Professional Organizations

  • Member, Board of Directors, American Rhinologic Society (2018 - Present)
  • Member, Scientific Program Committee, American Academy of Otolaryngology (2016 - Present)
  • Chair, Education Committee, American Rhinologic Society (2014 - 2017)
  • Member, Adult Sinusitis Guideline Committee, American Academy of Otolaryngology (2014 - 2015)
  • Member, Rhinology and Allergy Education Committee, American Academy of Otolaryngology (2013 - Present)
  • Member, Legislative Representatives Committee, Board of Governors, American Academy of Otolaryngology (2012 - Present)
  • Member, Program Committee, American Rhinologic Society (2012 - 2016)

Professional Education

  • Residency:Icahn School of Medicine at Mount Sinai Registrar (2010) NY
  • Internship:Icahn School of Medicine at Mount Sinai Registrar (2006) NY
  • Board Certification: Otolaryngology, American Board of Otolaryngology (2011)
  • Fellowship:Stanford School of Medicine (2011) CA
  • Medical Education:Oregon Health Science University (2005) OR

2018-19 Courses

All Publications

  • Rates of symptomatology are lower in recurrent sinonasal malignancy than in other recurrent cancers of the head and neck: a multi-institutional study. International forum of allergy & rhinology Workman, A. D., Velasquez, N., Khan, N. I., Borchard, N. A., Kuan, E. C., Palmer, J. N., Wang, E. W., Patel, Z. M., Adappa, N. D. 2019


    BACKGROUND: Sinonasal malignancies are a rare subset of head and neck tumors, and surveillance strategies after definitive tumor treatment are often generalized from those for overall head and neck cancer outcomes data. However, recent literature suggests that the posttreatment period in sinonasal cancer is fundamentally different and a more tailored surveillance approach may be beneficial. Although rates of symptomatology are high in head and neck cancer recurrence and patient-driven follow-up is common, rates of symptomatology are unknown in sinonasal cancer specifically.METHODS: Patients with recurrence of sinonasal malignancy were identified at 3 academic rhinology and skull base surgery centers. Demographic, tumor, and treatment data were collected. Rates of symptomatology at presentation were tabulated and examined in the context of several other variables.RESULTS: Fifty-five patients had recurrence of sinonasal malignancy after definitive treatment. Fifty-one percent of patients had no suspicious symptoms at the time of tumor recurrence, with an average time to recurrence of 33 months. Male patients and patients with stage IVA or lower disease were significantly more likely to be asymptomatic at the time of recurrence (p < 0.05).CONCLUSION: Patients with sinonasal malignancy have a much lower rate of symptomatology during tumor recurrence than that observed in head and neck cancer overall. Furthermore, time to recurrence is substantially longer, as a majority of head and neck cancer recurrences occur in the first 12 months after treatment. These differences highlight the need for more tailored surveillance paradigms in asymptomatic patients with a history of a definitively treated sinonasal neoplasm.

    View details for DOI 10.1002/alr.22310

    View details for PubMedID 30768764

  • The Horizon Sign and Frontal Bar: Two Topographic Landmarks to Confirm Endoscopic Frontal Sinusotomy. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Walgama, E. S., Thamboo, A., Tangbumrungtham, N., Ayoub, N., Patel, Z. M., Nayak, J. V. 2019: 194599818825472


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

    View details for DOI 10.1177/0194599818825472

    View details for PubMedID 30691380

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


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

    View details for DOI 10.1002/lary.27582

    View details for PubMedID 30515841

  • Therapeutic use of steroids in non-chronic rhinosinusitis olfactory dysfunction: a systematic evidence-based review with recommendations. International forum of allergy & rhinology Yan, C. H., Overdevest, J. B., Patel, Z. M. 2018


    BACKGROUND: Olfactory loss is a common and debilitating disease with limited treatment options, particularly for olfactory dysfunction not related to sinonasal inflammation. Both topical and systemic steroids have been used as treatments for olfactory loss. This study systematically reviews the literature on the efficacy of steroids for non-chronic rhinosinusitis (CRS)-related olfactory loss and provides recommendations.METHODS: A literature search of PubMed, Ovid, EMBASE, and the Cochrane Database was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Inclusion criteria included original data, English-language articles on steroid treatment (topical and systemic) for olfactory loss unrelated to sinonasal inflammation. Data was collected on study design, olfaction dysfunction etiology, clinical outcomes, and level of evidence. Two investigators reviewed all articles independently, with a third acting as a mediator for any disagreements in recommendation.RESULTS: Of 866 abstracts identified, only 15 studies met inclusion criteria and were systematically reviewed. Level 4 evidence suggests oral steroids can improve olfactory loss. Level 1B evidence demonstrates topical steroid rinses improve olfactory dysfunction in a select group of patients. Topical steroid sprays show no improvement across several levels of evidence.CONCLUSION: There is a paucity of high-quality studies demonstrating efficacy of either topical or oral steroids for olfactory dysfunction unrelated to sinonasal disease. The only level 1 evidence suggests using steroid rinses to improve olfactory outcomes in select patients, with weaker evidence supporting use of oral steroids. Topical steroid sprays do not improve olfactory dysfunction in this patient population and are not recommended.

    View details for DOI 10.1002/alr.22240

    View details for PubMedID 30472771

  • Oncologic management of sinonasal undifferentiated carcinoma. Current opinion in otolaryngology & head and neck surgery Tyler, M. A., Holmes, B., Patel, Z. M. 2018


    PURPOSE OF REVIEW: This article reviews the latest treatment paradigms in sinonasal undifferentiated carcinoma (SNUC).RECENT FINDINGS: The aggressive biology and associated advanced presentation of SNUC make successful treatment a challenge shared across medical specialties. Still, studies reporting outcomes in SNUC indicate that an aggressive treatment strategy consisting of surgery, radiation and chemotherapy offers the best chance of prolonged survival.SUMMARY: Successful treatment of SNUC requires highly specialized care at tertiary cancer treatment facilities. A better understanding of the biology of the disease coupled with increasing outcome reporting will lead to optimized treatment regimens.

    View details for DOI 10.1097/MOO.0000000000000513

    View details for PubMedID 30507692

  • Trans-Oral Endoscopic Resection of High Cervical Osteophytes with Long-term Symptom Resolution: Case Series, Imaging, and Literature Review. World neurosurgery Jabarkheel, R., Chen, Y., Xu, L., Yan, C. H., Patel, Z. M., Desai, A. M. 2018


    BACKGROUND: Anterior cervical osteophytes (ACOs) are a common radiological finding in the elderly; rarely, they can cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly found between C4-C7 and much less commonly at higher cervical levels. Here, we present a case series, with an example case of a 57-year-old woman with high cervical osteophytes at C1-C2 causing globus sensation, dysphagia, and dysphonia. Additionally, we provide a literature review regarding the etiology, diagnosis, and treatment of ACOs with a focus on management of high ACOs.CASE DESCRIPTION: A 57 year-old smoker with a history of chronic neck pain and previous cervical spinal instrumentation presented with several months of globus sensation, dysphagia, and dysphonia. Imaging revealed two large anterior osteophytes at C1-C2. She underwent endoscopic trans-oral osteophytectomy with resolution of symptoms. Five other patients are also presented who underwent similar procedures.CONCLUSIONS: ACOs are a potential cause of dysphagia, and their diagnosis is best made with CT imaging and oropharyngeal swallow study. Although high ACOs at C1-C2 are a rare finding, here we show with an exemplary case and small case series that they can be effectively treated with trans-oral endoscopic osteophytectomy.

    View details for DOI 10.1016/j.wneu.2018.08.188

    View details for PubMedID 30193964

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


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

    View details for DOI 10.1002/alr.22184

    View details for PubMedID 29999595

  • Budesonide irrigation with olfactory training improves outcomes compared with olfactory training alone in patients with olfactory loss. International forum of allergy & rhinology Nguyen, T. P., Patel, Z. M. 2018


    BACKGROUND: Olfactory training (OT) helps many patients with olfactory loss, but unfortunately it is ineffective for a significant number of patients. Budesonide irrigations are widely used to help patients with paranasal sinus inflammation, but have never been tested as a treatment for olfactory loss. We sought to examine the effect of adding budesonide irrigation to olfactory training on patients with olfactory loss without any visible sign of sinonasal inflammation.METHODS: In this randomized, controlled trial, 138 patients with olfactory loss and without any visible sign of sinonasal inflammation were randomized to either OT with saline irrigations or OT with budesonide irrigations. The University of Pennsylvania Smell Identification Test (UPSIT) was administered at the beginning of the study and at 6 months.RESULTS: A total of 133 patients completed the study. Forty-seven patients (35.3%) had a clinically significant change in UPSIT score. Among those in the budesonide irrigation + olfactory therapy group, 43.9% improved, compared with 26.9% in the saline irrigation + olfactory therapy group (p = 0.039); this corresponds to an odds ratio of 3.93 (95% confidence interval, 1.20-12.88) in a fully adjusted model (p = 0.024). Younger age and shorter duration of olfactory loss were also significant predictors of improvement.CONCLUSION: Adding budesonide irrigation to olfactory training significantly improved olfactory ability compared with olfactory training plus saline irrigation.

    View details for DOI 10.1002/alr.22140

    View details for PubMedID 29901865

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


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

    View details for DOI 10.1002/alr.22156

    View details for PubMedID 29856526

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


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

    View details for DOI 10.1002/alr.22147

    View details for PubMedID 29782068

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


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

    View details for DOI 10.1177/0194599818755340

    View details for Web of Science ID 000429905500026

    View details for PubMedID 29460675

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


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

    View details for DOI 10.1016/j.jaci.2017.05.032

    View details for Web of Science ID 000417206000010

    View details for PubMedID 28625807

    View details for PubMedCentralID PMC5723216

  • Outcomes After Endoscopic Endonasal Resection of Craniopharyngiomas in the Pediatric Population WORLD NEUROSURGERY Patel, V. S., Thamboo, A., Quon, J., Nayak, J. V., Hwang, P. H., Edwards, M., Patel, Z. M. 2017; 108: 6–14
  • Enhanced Tearing by Electrical Stimulation of the Anterior Ethmoid Nerve INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Brinton, M., Kossler, A. L., Patel, Z. M., Loudin, J., Franke, M., Ta, C. N., Palanker, D. 2017; 58 (4): 2341-2348


    Electrical neurostimulation enhances tear secretion, and can be applied to treatment of dry eye disease. Using a chronic implant, we evaluate the effects of stimulating the anterior ethmoid nerve on the aqueous, lipid, and protein content of secreted tears.Neurostimulators were implanted beneath the nasal mucosa in 13 New Zealand white rabbits. Stimulations (2.3-2.8 mA pulses of 75-875 μs in duration repeated at 30-100 Hz for 3 minutes) were performed daily, for 3 weeks to measure changes in tear volume (Schirmer test), osmolarity (TearLab osmometer), lipid (Oil-Red-O staining), and protein (BCA assay, mass spectrometry).Stimulation of the anterior ethmoid nerve in the frequency range of 30 to 90 Hz increased tear volume by 92% to 133% (P ≤ 0.01). Modulating the treatment with 50% duty cycle (3 seconds of stimulation repeated every 6 seconds) increased tear secretion an additional 23% above continuous stimulation (P ≤ 0.01). Tear secretion returned to baseline levels within 7 minutes after stimulation ended. Tear film osmolarity decreased by 7 mOsmol/L, tear lipid increased by 24% to 36% and protein concentration increased by 48% (P ≤ 0.05). Relative abundance of the lacrimal gland proteins remained the same, while several serum and corneal proteins decreased with stimulation (P ≤ 0.05).Electrical stimulation of the anterior ethmoid nerve increased aqueous tear volume, reduced tear osmolarity, added lipid, and increased the concentration of normal tear proteins. Human studies with an intranasal stimulator should verify these effects in patients with aqueous- and lipid-deficient forms of dry eye disease.

    View details for DOI 10.1167/iovs.16-21362

    View details for Web of Science ID 000400649600047

    View details for PubMedID 28431436

    View details for PubMedCentralID PMC5398789

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


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

    View details for DOI 10.1002/alr.21872

    View details for PubMedID 27863163

  • Office Procedures in Refractory Chronic Rhinosinusitis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Thamboo, A., Patel, Z. M. 2017; 50 (1): 113-?


    Office procedures in chronic rhinosinusitis (CRS) can be considered before and after medical management, as well as before and after surgical management. This article focuses specifically on refractory CRS, meaning those patients who have failed medical and surgical management already. The options available in the management of refractory CRS depend on the personnel, equipment, and instrumentation available in the office setting; surgeon experience; and patient suitability and tolerability. This article provides readers with possible procedural options that can be done in their clinics with indications, patient selection, potential complications, and postoperative considerations.

    View details for DOI 10.1016/j.otc.2016.08.010

    View details for Web of Science ID 000390983700010

    View details for PubMedID 27888908

  • The evidence for olfactory training in treating patients with olfactory loss CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Patel, Z. M. 2017; 25 (1): 43-46


    The purpose of this review is to go over the only therapy for olfactory loss supported by level 1a evidence that is currently available, which is olfactory training. This therapy is widely underutilized and has the potential to help many patients with olfactory dysfunction who are otherwise offered no management options.We will review the rationale, clinical studies, and quality of the evidence regarding olfactory training, specifically the olfactory system's inherent ability to regenerate, the plasticity of the system, and the multiple protocols and modifications of protocols present in the literature.Olfactory training is an effective therapy for some patients suffering from olfactory loss, and, while we do not yet know the optimal duration or number of odorants or exact patient population it may be most beneficial for, as an extremely easy, self-driven therapy with no significant side-effects, it should be consistently offered to this patient population.

    View details for DOI 10.1097/MOO.0000000000000328

    View details for Web of Science ID 000392100000009

    View details for PubMedID 27841770

  • Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Shahangian, A., Soler, Z. M., Baker, A., Wise, S. K., Rereddy, S. K., Patel, Z. M., Oyesiku, N. M., DelGaudio, J. M., Hadjipanayis, C. G., Woodworth, B. A., Riley, K. O., Lee, J., Cusimano, M. D., Govindaraj, S., Khan, M. N., Psaltis, A., Wormald, P. J., Santoreneos, S., Sindwani, R., Trosman, S., Stokken, J. K., Woodard, T. D., Recinos, P. F., Vandergrift, W. A., Boling, C., Schlosser, R. J. 2017; 7 (1): 80-86


    The impact of failed cerebrospinal fluid leak (CSF) leak repair in endoscopic skull base surgery has not been adequately studied.In this investigation we reviewed patients who had undergone endoscopic skull base surgery between 2002 and 2014 at 7 international centers. Demographic variables, comorbidities, tumor characteristics, and repair techniques were evaluated to determine association with successful repair of CSF leak. Postoperative complications and length of stay were compared among groups.Data were collected on 2097 patients who were divided into 3 groups: (1) those with no intraoperative leak (n = 1533); (2) those with successful repair of their intraoperative leak (n = 452); and (3) those with failed repair (n = 112). Compared with successful repair, failed repair was associated with an increased risk of intracranial infection (odds ratio [OR], 5.6; 95% confidence interval [CI], 5.3-13.15), pneumocephalus (OR, 16; 95% CI, 5.8-44.4), 30-day readmission (OR, 8.4; 95% CI, 5.3-13.5), reoperation (OR, 115.4; 95% CI, 56.3-236.8), and prolonged hospital stay (14.9 vs 7.0 days, p < 0.01). Outcomes in patients who had successful repairs of intraoperative leaks were similar to those who never had leakage. Intraoperative use of pedicled nasoseptal flaps was associated with successful repair (OR, 0.60; 95% CI, 0.34-0.92).Intraoperative CSF leaks are a frequent and expected occurrence during endoscopic skull base surgery. Failed CSF leak repair has a significant impact on patient outcomes, with increased rates of postoperative pneumocephalus, intracranial infections, reoperation, deep vein thrombosis, readmission, and prolonged hospital stay. Recognition and repair of intraoperative CSF leaks reduces postoperative complications. Use of pedicled nasoseptal flaps improves outcomes in reconstructing defects at higher risk for postoperative leak.

    View details for DOI 10.1002/alr.21845

    View details for Web of Science ID 000394900500012

    View details for PubMedID 27579523

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


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

    View details for DOI 10.1002/lary.26907

    View details for PubMedID 29068050

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


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

    View details for DOI 10.1002/alr.22032

    View details for PubMedID 29131540

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


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

    View details for DOI 10.1002/alr.22056

    View details for PubMedID 29227048

  • Randomized Controlled Trial Demonstrating Cost-Effective Method of Olfactory Training in Clinical Practice Laryngoscope Investigative Otolaryngology Patel, Z. M., Wise, S. K., DelGaudio, J. M. 2017: 53–56


    Published data examining the efficacy of olfactory training (OT) has used standardized concentrations of odorants and the Sniffin' Sticks testing method. Although well-validated, these methods are costly and time-intensive for the average otolaryngology practice. The purpose of our study was to evaluate the efficacy of using essential oils at random concentrations and the University of Pennsylvania Smell Test (UPSIT) for training and testing, and compare this with the existing data on OT.Randomized Clinical TrialMethods: Patients presenting to a tertiary care rhinology center with subjective loss of smell and olfactory loss measured by UPSIT were randomized to OT or control for 6 months. Only patients with loss of smell greater than one-year duration, and loss associated with post-infectious and idiopathic etiologies were included. Baseline UPSIT was compared to 6-month UPSIT. An accepted 10% change or better was used to establish a significant improvement on UPSIT.43 patients were enrolled. Eight patients were lost to follow-up, with a total of 35 completing the study. Age ranged from 39-71 with an average of 56. Of 19 patients in the OT group, 6 showed significant improvement (32%), while only two out of 16 patients (13%) in the control group improved. Increasing age and duration of loss were significantly correlated to lack of improvement.Allowing patients to use random concentrations of essential oils to perform OT is as effective as published data using controlled concentrations of odorants for post-infectious and idiopathic olfactory loss.1b.

    View details for DOI 10.1002/lio2.62

    View details for PubMedCentralID PMC5527365

  • Barosinusitis: Comprehensive review and proposed new classification system. Allergy & rhinology (Providence, R.I.) Vaezeafshar, R., Psaltis, A. J., Rao, V. K., Zarabanda, D., Patel, Z. M., Nayak, J. V. 2017; 8 (3): 109–17


    Barosinusitis, or sinus barotrauma, may arise from changes in ambient pressure that are not compensated by force equalization mechanisms within the paranasal sinuses. Barosinusitis is most commonly seen with barometric changes during flight or diving. Understanding and better classifying the pathophysiology, clinical presentation, and management of barosinusitis are essential to improve patient care.To perform a comprehensive review of the available literature regarding sinus barotrauma.A comprehensive literature search that used the terms "barosinusitis," "sinus barotrauma," and "aerosinusitis" was conducted, and all identified titles were reviewed for relevance to the upper airway and paranasal sinuses. All case reports, series, and review articles that were identified from this search were included. Selected cases of sinus barotrauma from our institution were included to illustrate classic signs and symptoms.Fifty-one articles were identified as specifically relevant to, or referencing, barosinusitis and were incorporated into this review. The majority of articles focused on barosinusitis in the context of a single specific etiology rather than independent of etiology. From analysis of all the publications combined with clinical experience, we proposed that barosinusitis seemed to fall within three distinct subtypes: (1) acute, isolated barosinusitis; (2) recurrent acute barosinusitis; and (3) chronic barosinusitis. We introduced this terminology and suggested independent treatment recommendations for each subtype.Barosinusitis is a common but potentially overlooked condition that is primed by shifts in the ambient pressure within the paranasal sinuses. The pathophysiology of barosinusitis has disparate causes, which likely contribute to its misdiagnosis and underdiagnosis. Available literature compelled our proposed modifications to existing classification schemes, which may allow for improved awareness and management strategies for barosinusitis.

    View details for DOI 10.2500/ar.2017.8.0221

    View details for PubMedID 29070267

    View details for PubMedCentralID PMC5662535

  • Variables associated with olfactory disorders in adults: A U.S. population-based analysis. World journal of otorhinolaryngology - head and neck surgery Noel, J., Habib, A. R., Thamboo, A., Patel, Z. M. 2017; 3 (1): 9–16


    Olfactory dysfunction is known to have significant social, psychological, and safety implications. Despite increasingly recognized prevalence, potential risk factors for olfactory loss have been arbitrarily documented and knowledge is limited in scale. The aim of this study is to identify potential demographic and exposure variables correlating with olfactory dysfunction.Cross-sectional analysis of the 2011-2012 and 2013-2014 editions of the National Health Examination and Nutrition Survey was performed. The utilized survey reports from a nationally representative sample of about 5000 persons each year located in counties across the United States. There is an interview and physical examination component which includes demographic, socioeconomic, dietary, and health-related questions as well as medical, dental, physiologic measurements, and laboratory tests. 3594 adult respondents from 2011 to 2012 and 3708 respondents from 2013 to 2014 were identified from the above population-based database. The frequency of self-reported disorders as well as performance on odor identification testing was determined in relation to demographic factors, occupational or environmental exposures, and urinary levels of environmental and industrial compounds.In both subjective and objective analysis, smell disorders were significantly more common with increasing age. While the non-Hispanic Black and non-Hispanic Asian populations were less likely to report subjective olfactory loss, they, along with Hispanics, performed more poorly on odor identification than Caucasians. Those with limited education had a decreased prevalence of hyposmia. Women outperformed men on smell testing. Those reporting exposure to vapors were more likely to experience olfactory dysfunction, and urinary levels of manganese, 2-Thioxothiazolidine-4-carboxylic acid, and 2-Aminothiazoline-4-carboxylic acid were lower among respondents with subjective smell disturbance. In odor detection, elevated serum levels of lead and urinary levels of 2,4 dichlorophenol were associated with anosmia and hyposmia, respectively.This study provides current, population-based data identifying demographic and exposure elements related to smell disturbances in U.S. adults. Age, race, gender, education, exposure to vapors, urinary levels of manganese, 2-Thioxothiazolidine-4-carboxylic acid, 2-Aminothiazoline-4-carboxylic acid, 2,4 dichlorophenol, and serum lead levels were all implicated in smell disturbance. Care should be taken in interpretation due to lack of consistency between subjective and objective measures of olfaction as well as limitations related to population-based data. Prospective trials are indicated to further elucidate these relationships.

    View details for DOI 10.1016/j.wjorl.2017.02.005

    View details for PubMedID 29204574

    View details for PubMedCentralID PMC5683598

  • Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery. International forum of allergy & rhinology Karnezis, T. T., Baker, A. B., Soler, Z. M., Wise, S. K., Rereddy, S. K., Patel, Z. M., Oyesiku, N. M., DelGaudio, J. M., Hadjipanayis, C. G., Woodworth, B. A., Riley, K. O., Lee, J., Cusimano, M. D., Govindaraj, S., Psaltis, A., Wormald, P. J., Santoreneos, S., Sindwani, R., Trosman, S., Stokken, J. K., Woodard, T. D., Recinos, P. F., Vandergrift, W. A., Schlosser, R. J. 2016; 6 (11): 1117-1125


    In patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information.A retrospective review of patients undergoing endoscopic sellar surgery for pituitary adenomas or craniopharyngiomas between 2002 and 2014 at 7 international centers was performed. Demographic, comorbidity, and tumor characteristics were evaluated to determine the associations between intraoperative and postoperative CSF leaks. Correlations between reconstructive and CSF diversion techniques were associated with postoperative CSF leak rates. Odds ratios (OR) were identified using a multivariate logistic regression model.Data were collected on 1108 pituitary adenomas and 53 craniopharyngiomas. Overall, 30.1% of patients had an intraoperative leak and 5.9% had a postoperative leak. Preoperative factors associated with increased intraoperative leaks were mild liver disease, craniopharyngioma, and extension into the anterior cranial fossa. In patients with intraoperative CSF leaks, postoperative leaks occurred in 10.3%, with a higher postoperative leak rate in craniopharyngiomas (20.8% vs 5.1% in pituitary adenomas). Once an intraoperative leak occurred, craniopharyngioma (OR = 4.255, p = 0.010) and higher body mass index (BMI) predicted postoperative leak (OR = 1.055, p = 0.010). In patients with an intraoperative leak, the use of septal flaps reduced the occurrence of postoperative leak (OR = 0.431, p = 0.027). Rigid reconstruction and CSF diversion techniques did not impact postoperative leak rates.Intraoperative CSF leaks can occur during endoscopic sellar surgery, especially in larger tumors or craniopharyngiomas. Once an intraoperative leak occurs, risk factors for postoperative leaks include craniopharyngiomas and higher BMI. Use of septal flaps decreases this risk.

    View details for DOI 10.1002/alr.21783

    View details for PubMedID 27552303

  • Determinants of racial differences in survival for sinonasal cancer. Laryngoscope Patel, Z. M., Li, J., Chen, A. Y., Ward, K. C. 2016; 126 (9): 2022-2028


    Racial differences in survival are present across multiple cancer types, including sinonasal cancer. Thus far in the literature, reasons for this have been theorized but not proven. We aimed to examine proposed potential factors and understand the true determinants in racial differences for survival in sinonasal cancer.Utilizing the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2000-2008), we analyzed multiple demographic, tumor-related, and treatment-related factors. Use of the Medicare subset allows much deeper examination of patient and treatment factors than the usual SEER database study.Univariate analysis and multivariate Cox proportional hazard regression models were used.Eight hundred and forty-five patients remained after exclusion criteria. Five-year cause-specific survival (CSS) was 62%, with a racial difference confirmed because non-Hispanic whites (NHW) and blacks and Hispanic whites (B/HW) demonstrated 64% and 52% CSS, respectively. After multivariate analysis, factors significantly determining racial survival were age, stage, histology, grade, comorbidity status, and standard of care.This study confirms the difference in racial survival in sinonasal cancer. In opposition to popular theories of access to care and education level- and poverty level-determining outcomes, those factors were not significant on multivariate analysis, whereas stage and receiving standard of care, determined by unimodality versus multimodality treatment appropriate to stage, were the two most important prognostic factors.2c. Laryngoscope, 126:2022-2028, 2016.

    View details for DOI 10.1002/lary.25897

    View details for PubMedID 26915596

  • Immunotherapy compliance: comparison of subcutaneous versus sublingual immunotherapy INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Leader, B. A., Rotella, M., Stillman, L., DelGaudio, J. M., Patel, Z. M., Wise, S. K. 2016; 6 (5): 460-464


    Patient compliance is critical for successful allergen immunotherapy (AIT). Previous studies suggest that AIT compliance is worse outside of controlled clinical trials, with reported subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) noncompliance at 11% to 50% and 3% to 25%, respectively.A retrospective review of 384 AIT patients at a single, tertiary care otolaryngic allergy practice evaluated SCIT and SLIT compliance, based on treatment stage. SCIT compliance was defined as the number of 2-week breaks per year or in compliance with their defined schedule: excellent = 2 or fewer; good = 3 to 4; fair = 5 to 6; and poor = 7 or more. Compliance with SLIT was defined as the number of days vials were refilled within the defined expiration date: excellent = 10 days or fewer; good = 11 to 15 days, fair = 16 to 20 days; and poor = 25 or more days. Fisher exact and chi square tests were used for statistical analysis.Seventy-four SCIT and 200 SLIT patients had data appropriate for analysis. Compliance rates were excellent (62%) or good (22%) in 62 SCIT patients and excellent (31%) or good (35%) in 131 SLIT patients. Comparing excellent compliance rates, SCIT patients had a higher rate of excellent compliance at all stages of treatment compared to SLIT patients (p < 0.05). For SCIT patients there was no significant difference in excellent compliance rates between escalation, first year of maintenance, and greater than 1 year of maintenance (p > 0.05).The results of this study showed higher rates of patient adherence to treatment protocols among SCIT patients. There was no decrease in SCIT compliance rates across treatment stages.

    View details for DOI 10.1002/alr.21699

    View details for Web of Science ID 000375917100003

    View details for PubMedID 26718480

  • Olfaction following endoscopic skull base surgery CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Patel, Z. M., DelGaudio, J. M. 2016; 24 (1): 70-74


    As endoscopic skull base surgery advances and becomes more common, recognizing and understanding all possible risks and complications of these procedures is a significant responsibility of the operating surgeon. Olfaction is a deficit often ignored or trivialized by the treating physician, in spite of its loss causing major impacts on our patients' quality of life.Olfactory dysfunction after endoscopic skull base surgery is still being debated in the literature, with evidence supporting both sides. With some studies denying any loss, others suggesting temporary deficits, and still others showing long-term damage, standardization of testing and high levels of awareness of this possible complication should be the prevailing practice.Future goals of any endoscopic skull base surgeon should be to use objective olfactory testing before and after surgery, collect information on rates of dysfunction in their patients, and offer treatment options as necessary while tracking the efficacy of those options in this patient population.

    View details for DOI 10.1097/MOO.0000000000000216

    View details for Web of Science ID 000367599300013

  • Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Boling, C. C., Karnezis, T. T., Baker, A. B., Lawrence, L. A., Soler, Z. M., Vandergrift, W. A., Wise, S. K., DelGaudio, J. M., Patel, Z. M., Rereddy, S. K., Lee, J. M., Khan, M. N., Govindaraj, S., Chan, C., Oue, S., Psaltis, A. J., Wormald, P., Trosman, S., Stokken, J., Woodard, T., Sindwani, R., Schlosser, R. J. 2016; 6 (1): 101-107


    The goal of this study was to identify preoperative risk factors associated with increased perioperative morbidity after endoscopic pituitary surgery.A retrospective review of patients undergoing endoscopic pituitary adenoma surgery between 2002 and 2014 at 6 international centers was performed. Standard demographic and comorbidity data, as well as information regarding tumor extent and treatment were collected. Logistic regression was used to examine risk factors for the following 30-day outcomes: systemic complications, intracranial complications, postoperative cerebrospinal fluid (CSF) leaks, length of hospital stay, readmission, and reoperation.Data was collected on 982 patients with a mean age of 52 years. The median body mass index (BMI) for all patients was 30.9 kg/m(2) with 56% female. The median hospital stay was 5 days and 23.8% of patients suffered a postoperative adverse event. Systemic complications occurred in 3.2% of patients and intraventricular extension was a risk factor (odds ratio [OR] 8.9). Intracranial complications occurred in 7.3% of patients and risk factors included previous radiation (OR 8.6) and intraventricular extension (OR 7.9). Reoperation occurred in 6.5% of patients and intraventricular extension (OR 7.3) and age (<40 years, OR 3.5; 40 to 64 years, OR 3.2) were risk factors. Postoperative CSF leaks occurred in 5.5% of patients and risk factors included female gender (OR 2.4), BMI ≥ 30 (OR 2.1), age (<40 years, OR 5.3; 40 to 64 years, OR, 7.9), and intraventricular extension (OR, 9.5).Postoperative endoscopic pituitary adenoma surgery complications are associated with tumors with intraventricular extension, preoperative radiation, as well as common patient comorbidities. Identification of these factors may permit implementation of strategies to reduce postoperative complications.

    View details for DOI 10.1002/alr.21622

    View details for Web of Science ID 000368007900015

    View details for PubMedID 26250607

  • Management of non-invasive rhinosinusitis in the immunosuppressed patient population LARYNGOSCOPE Dao, A. M., Rereddy, S. K., Wise, S. K., DelGaudio, J. M., Patel, Z. M. 2015; 125 (8): 1767-1771


    Rhinologists are seeing an increasing number of immunosuppressed patients. Currently, no treatment paradigm exists for treating acute and chronic noninvasive rhinosinusitis (ARS, CRS) in this growing population. This study aims to identify patient and treatment factors that affect rhinosinusitis outcomes in this vulnerable population.Prognostic retrospective cohort study.Immunocompromised patients treated by rhinologists for ARS or CRS 10/2007 to 10/2012 were identified by rhinosinusitis diagnostic codes, codes for transplant, cancer, HIV, diabetes, and codes indicating immunosuppression in the intensive care setting. Associations between patient factors and outcome were analyzed by logistic regression. Associations between treatment and outcome were analyzed by Firth logistic regression.A total of 132 subjects were identified. Of those, 90.9% had CRS and 9.1% had ARS; 12.9% were transplant patients; 47% were diabetic; 37.9% were cancer patients; and 16.7% were in the intensive care unit. Patients with higher American Society of Anesthesiologists (ASA) scores had decreased disease resolution (odds ratio [OR] = 0.5, P = 0.021). Transplant patients (OR = 22.5, P = 0.001), diabetics patients (OR = 6.4, P = 0.017), cancer patients (OR = 5.4, P = 0.046), and patients with prior medical therapy for rhinosinusitis (OR = 5.84, P < 0.001) had increased disease resolution compared to immunosuppressed critical care patients. Patients treated with antibiotics alone had no statistically significant difference in disease resolution compared to those receiving no treatment. In contrast, treatment plans including surgery were associated with greater disease resolution.This data indicates that surgical treatment provides improved outcomes for patients presenting with acute exacerbations of rhinosinusitis related to their immunocompromised state. Given the limited study population, these findings may not apply to HIV-positive or ARS patients, and further study should be undertaken in these groups.4.

    View details for DOI 10.1002/lary.25305

    View details for Web of Science ID 000358379700012

    View details for PubMedID 25946593

  • Clinical Practice Guideline (Update): Adult Sinusitis OTOLARYNGOLOGY-HEAD AND NECK SURGERY Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Kumar, K. A., Kramper, M., Orlandi, R. R., Palmer, J. N., Patel, Z. M., Peters, A., Walsh, S. A., Corrigan, M. D. 2015; 152: S1-S39


    This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

    View details for DOI 10.1177/0194599815572097

    View details for Web of Science ID 000352577900001

    View details for PubMedID 25832968

  • Clinical Practice Guideline (Update): Adult Sinusitis Executive Summary OTOLARYNGOLOGY-HEAD AND NECK SURGERY Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Kumar, K. A., Kramper, M., Orlandi, R. R., Palmer, J. N., Patel, Z. M., Peters, A., Walsh, S. A., Corrigan, M. D. 2015; 152 (4): 598-609


    The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue featuring the updated "Clinical Practice Guideline: Adult Sinusitis" as a supplement to Otolaryngology-Head and Neck Surgery. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 developed recommendations address diagnostic accuracy for adult rhinosinusitis, the appropriate use of ancillary tests to confirm diagnosis and guide management (including radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function), and the judicious use of systemic and topical therapy. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. An updated guideline is needed as a result of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

    View details for DOI 10.1177/0194599815574247

    View details for Web of Science ID 000352580000011

    View details for PubMedID 25833927

  • Magnetic resonance cisternogram with intrathecal gadolinium with delayed imaging for difficult to diagnose cerebrospinal fluid leaks of anterior skull base INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY DelGaudio, J. M., Baugnon, K. L., Wise, S. K., Patel, Z. M., Aiken, A. H., Hudgins, P. A. 2015; 5 (4): 333-338


    Workup of cerebrospinal fluid (CSF) leaks can be challenging. Patients with intermittent or infrequent clear rhinorrhea that cannot be collected, those with questionable or multiple skull-base (SB) defects on imaging, and those with previous SB surgery can present diagnostic dilemmas. In this patient population, radiologic studies that allow repeat imaging over hours to days can increase the diagnostic yield. We report our experience with magnetic resonance cisternogram with intrathecal gadolinium (MRCgGd) in this patient population.This study was a retrospective review of patients who underwent MRCgGd for workup of suspected CSF leaks at a tertiary care academic center.Over the past 3 years, 11 patients (10 females; mean age 50 years) underwent MRCgGd. Seven patients had suspected spontaneous CSF leaks from idiopathic intracranial hypertension and 2 had postsurgical defects. All patients had previous imaging that was indeterminate in localizing the site of the leak. Only 3 patients had positive beta-2 transferrin studies, all with multiple potential leak sites. MRCgGd confirmed the absence of leaks at 4 previously repaired SB defects, identified spinal canal leaks but no SB leaks in 2 patients (1 of whom had a nonleaking SB defect), and identified 5 patients with one or more SB leaks. Repeat imaging, from 30 minutes to 20 hours, was beneficial in identifying 4 leaks not confirmed in the immediate imaging, and ruling out leaks in 5 cases, therefore guiding further treatment. No complications occurred.MRCgGd is a useful diagnostic test in the workup of patients with difficult CSF leaks, with delayed imaging providing valuable diagnostic information.

    View details for DOI 10.1002/alr.21475

    View details for Web of Science ID 000352580700012

    View details for PubMedID 25561376

  • Association of Decreased Rate of Influenza Vaccination With Increased Subjective Olfactory Dysfunction JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY Flanagan, C. E., Wise, S. K., DelGaudio, J. M., Patel, Z. M. 2015; 141 (3): 225-228


    Seasonal influenza causes significant morbidity and mortality, with cardiovascular and respiratory complications the most common among susceptible individuals. Upper respiratory tract infections (URIs) are known to precede olfactory dysfunction in some patients. To our knowledge, there has been no study assessing the possible relationship between influenza vaccination status and olfactory dysfunction.To compare vaccination status of a group of patients with subjective olfactory dysfunction with that of a group of controls.Retrospective medical record review and telephone survey in a matched case-control study. Forty-two patients were identified via diagnosis codes who presented to a tertiary care academic rhinologic center with subjective smell dysfunction over the course of 1 year. Only post-URI and idiopathic etiologies were included. Forty-two age-, sex-, and race/ethnicity-matched control patients were also selected.Demographic data, influenza vaccination status, and smoking status were reviewed. χ² Testing was used.We were able to obtain vaccination data for 36 of 42 patients in the olfactory dysfunction group and 38 of 42 in the control group. Seven of the 36 (19%) in the olfactory dysfunction group had received the vaccine in the year prior to presentation compared with 16 of 38 (42%) in the control group (P = .04).Influenza vaccination seems to be associated with a decreased rate of subjective olfactory dysfunction. This is a preliminary finding, and further studies would be needed to elucidate the exact role of influenza and influenza vaccination in patients with olfactory loss.

    View details for DOI 10.1001/jamaoto.2014.3399

    View details for Web of Science ID 000351585000006

    View details for PubMedID 25590362

  • Higher Body Mass Index Is Associated with Subjective Olfactory Dysfunction BEHAVIOURAL NEUROLOGY Patel, Z. M., DelGaudio, J. M., Wise, S. K. 2015


    Morbidly obese patients demonstrate altered olfactory acuity. There has been no study directly assessing Body Mass Index (BMI) in patients with olfactory dysfunction. Our purpose was to compare BMI in a group of patients with subjective olfactory dysfunction to those without subjective olfactory complaints.Retrospective matched case-control study. Sixty patients who presented to a tertiary care otolaryngology center with subjective smell dysfunction over one year were identified. Neoplastic and obstructive etiologies were excluded. Demographics, BMI, and smoking status were reviewed. Sixty age, gender, and race matched control patients were selected for comparison. Chi-square testing was used.48 out of 60 patients (80%) in the olfactory dysfunction group fell into the overweight or obese categories, compared to 36 out of 60 patients (60%) in the control group. There was a statistically significant difference between the olfactory dysfunction and control groups for this stratified BMI (p = 0.0168).  This study suggests high BMI is associated with olfactory dysfunction. Prospective clinical research should examine this further to determine if increasing BMI may be a risk factor in olfactory loss and to elucidate what role olfactory loss may play in diet and feeding habits of obese patients.

    View details for DOI 10.1155/2015/675635

    View details for Web of Science ID 000357531900001

    View details for PubMedID 26199458

  • Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery. International Forum of Allergy and Rhinology Boling, C. 2015
  • Endoscopic transsphenoidal pituitary surgery: transsphenoidal approach to the sella and sellar closure with septal flap: 3-dimensional operative video. Neurosurgery Chu, J., Wise, S. K., Patel, Z. M., Oyesiku, N. M. 2014; 10: 654-?

    View details for DOI 10.1227/NEU.0000000000000469

    View details for PubMedID 25409331

  • The nasal floor pedicled flap: a novel technique for use in skull base reconstruction INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Daraei, P., Oyesiku, N. M., Patel, Z. M. 2014; 4 (11): 937-943


    Skull base reconstruction can be accomplished using various donor sites. Vascularized tissue, commonly the nasoseptal flap, is the most effective option for large defects or high flow leaks. In cases where the septum cannot be used, a mucoperiosteal flap from the nasal floor, pedicled from the sphenopalatine artery, is a viable option without reported outcomes. The aim of this work was to describe this flap and to report successful outcomes in a cohort of patients.Retrospective chart review of patients seen by the senior author from 2011 to 2013 requiring skull base reconstruction for defects with cerebrospinal fluid leak.A total of 108 patients underwent endoscopic skull base reconstruction. Ten patients had reconstruction with use of a pedicled nasal floor flap. Mean age was 53.3 years. Defects involved the ethmoid roof in 5 patients, sellar floor in 2, clivus in 2, and planum sphenoidale in 1. Reasons why the septal flap could not be used were intentional sacrifice due to disease involvement, sacrifice for proper exposure, or previous septal perforation. Mean length of follow-up was 10.2 (range, 4 to 25) months. No patient developed cerebrospinal fluid leaks postoperatively.Nasal floor pedicled flaps are an effective alternative to nasoseptal flaps for reconstruction of the skull base, and have not been previously described in the literature. Outcomes are promising in our small cohort of patients. If the septum must be sacrificed, attention should be paid to the nasal floor, which provides a large mucoperiosteal flap that can be consistently exposed and elevated by the experienced surgeon.

    View details for DOI 10.1002/alr.21369

    View details for Web of Science ID 000344361600013

    View details for PubMedID 25224141

  • Evaluation and Management of "Sinus Headache" in the Otolaryngology Practice OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Patel, Z. M., Setzen, M., Poetker, D. M., DelGaudio, J. M. 2014; 47 (2): 269-?


    Patients, primary care doctors, neurologists and otolaryngologists often have differing views on what is truly causing headache in the sinonasal region. This review discusses common primary headache diagnoses that can masquerade as "sinus headache" or "rhinogenic headache," such as migraine, trigeminal neuralgia, tension-type headache, temporomandibular joint dysfunction, giant cell arteritis (also known as temporal arteritis) and medication overuse headache, as well as the trigeminal autonomic cephalalgias, including cluster headache, paroxysmal hemicrania, and hemicrania continua. Diagnostic criteria are discussed and evidence outlined that allows physicians to make better clinical diagnoses and point patients toward better treatment options.

    View details for DOI 10.1016/j.otc.2013.10.008

    View details for Web of Science ID 000334894500009

    View details for PubMedID 24680494

  • Practice patterns regarding noninvasive rhinosinusitis in the immunosuppressed patient population. Allergy & rhinology (Providence, R.I.) Patel, Z. M. 2013; 4 (3): e151-4


    The number of immunosuppressed patients is growing remarkably. Currently, there is no guideline on how treatment of noninvasive sinusitis in these patients may differ from that of the general population, and practice patterns vary widely across the country. The purpose of this survey was to examine practice patterns and management for this patient population. A survey and literature review were performed. The survey was sent to the membership list serve of the American Rhinologic Society. Twelve questions were asked. Four demographic questions were asked about the physicians and their practices. Four questions were asked about the type of immunocompromised patients they saw. Two questions were asked about management in the setting of significant acute and chronic sinusitis. The responses were collected and analyzed using Pearson independent chi-square testing. Of 871 members on the list serve only 89 physicians responded. The majority of responders were sinus and skull base surgeons practicing in an academic setting. There was a large range of geographic location, years in practice, and patient population. Two significant findings related years in practice to management of chronic sinus immunocompromised patients (p = 0.012) and correlated the choice of management option in acute and chronic sinus immunocompromised patients (p = 0.006). There is no standardized method of treating the vulnerable patient population of immunocompromised patients with noninvasive acute and chronic sinusitis and this survey shows the wide range of practice. Clinical research is needed to standardize and optimize treatment for these patients.

    View details for DOI 10.2500/ar.2013.4.0070

    View details for PubMedID 24498520

  • Comparing use of the Sonopet((R)) ultrasonic bone aspirator to traditional instrumentation during the endoscopic transsphenoidal approach in pituitary tumor resection INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Baddour, H. M., Lupa, M. D., Patel, Z. M. 2013; 3 (7): 588-591


    The Sonopet(®) ultrasonic bone aspirator (Stryker(®) , Kalamazoo, MI) has been used within neurosurgery, otolaryngology and in other fields, but to our knowledge has not been reported in the literature for use in endoscopic transsphenoidal approaches (TSAs) to the skull base. The study objective was to compare use of the ultrasonic bone aspirator (UBA) vs traditional cold steel instrumentation during TSA in terms of operative time and blood loss.The study design was a prospective, randomized, single-blinded controlled clinical trial. The population included patients who presented to a tertiary care skull base center with pituitary tumors amenable to endoscopic resection. Participants were randomized to either an endoscopic approach using the ultrasonic bone aspirator (n = 66) or traditional steel instrumentation (n = 64). Outcomes measured were operative time and blood loss for the approach and exposure portion of the procedure.The use of the UBA resulted in a significant reduction in both operative time (31.92 ± 3.04 minutes vs 41.32 ± 2.75 minutes, p < 0.0001) and blood loss (16.5 ± 5.37 milliliters vs 22.57 ± 3.09 milliliters, p < 0.0001) compared to traditional steel instrumentation.This study is, to our knowledge, the first prospective, randomized, controlled clinical trial comparatively demonstrating the speed, safety and efficacy of the ultrasonic bone aspirator for endoscopic TSA to the skull base. Although the UBA offers surgical benefits, the cost of disposables may limit its usefulness to use in tertiary care institutions where operative cost can be shared across departments and with the hospital.

    View details for DOI 10.1002/alr.21143

    View details for Web of Science ID 000322036500011

    View details for PubMedID 23292661

  • Concurrent functional endoscopic sinus surgery and septorhinoplasty: using evidence to make clinical decisions INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Patel, Z. M., Setzen, M., Sclafani, A. P., Del Gaudio, J. M. 2013; 3 (6): 488-492


    Concurrent septorhinoplasty (SRP) and functional endoscopic sinus surgery (FESS) has been a controversial topic in the literature over the last decade. Warnings and admonitions about the risks of performing these procedures together in a single surgery are both published and voiced at national meetings. Although pros and cons have been discussed in the literature, there have been no guidelines published based solely on a review of the level of evidence.A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were an adult population >18 years old, description or implication of study design available, concurrent FESS and SRP performed without additional procedures, and report of complications included in the study.We identified and evaluated the literature meeting those criteria: 11 retrospective studies. The literature was reviewed for both quality of research design as well as benefit and harm of the proposed interventions.If a patient is in need of FESS and SRP, either for functional or cosmetic reasons, and is found on the risk matrix to either have low or moderate risk, that patient is a good candidate for a concurrent procedure. If the patient is found to have higher risk, it is not an absolute contraindication, but the surgeon must use best clinical judgment when deciding to move forward and must counsel the patient preoperatively about possible increased risks.

    View details for DOI 10.1002/alr.21130

    View details for Web of Science ID 000320929300009

    View details for PubMedID 23293086

  • "Sinus headache": rhinogenic headache or migraine? An evidence-based guide to diagnosis and treatment INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Patel, Z. M., Kennedy, D. W., Setzen, M., Poetker, D. M., DelGaudio, J. M. 2013; 3 (3): 221-230


    Patients present to physicians across multiple disciplines with the complaint of sinus headache. This lay term is widely accepted in the media, yet has been repeatedly questioned in the medical literature, and experts in the fields of otolaryngology, neurology, and allergy have agreed that it is an overused and often incorrect diagnosis in the majority of patients. There have been review articles and consensus panels established regarding this issue, but thus far no guidelines based purely on a review of the level of evidence provided by the literature.A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were: adult population >18 years old, self-diagnosed or physician-diagnosed "sinus headache," clearly defined diagnostic criteria in diagnostic studies, and clearly defined primary clinical end-point in therapeutic studies.We identified and evaluated the literature on diagnosing and treating patients with a primary complaint of sinus headache. The literature was reviewed for both quality of research design as well as benefit and harm of the proposed interventions.If a thorough neurologic and otolaryngologic evaluation is performed, the majority of patients presenting with sinus headache in the absence of significant acute inflammatory findings will be diagnosed with migraine. In this situation, the appropriate treatment for the majority of patients presenting with sinus headache is migraine directed therapy. In a highly select group of patients, directed nasal surgery addressing endonasal contact points may be an option.

    View details for DOI 10.1002/alr.21095

    View details for Web of Science ID 000316265000011

    View details for PubMedID 23129234

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


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

    View details for DOI 10.1002/alr.21039

    View details for Web of Science ID 000308927400007

    View details for PubMedID 22528624

  • The Prevention and Management of Complications in Ethmoid Sinus Surgery OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Patel, Z. M., Govindaraj, S. 2010; 43 (4): 855-?


    Prevention of complications during ethmoid sinus surgery begins with sound knowledge of the relevant anatomy, preoperative planning with use of radiologic imaging, and careful, thoughtful dissection intraoperatively. Despite these measures, however, complications may occur. This article highlights potential complications and treatment techniques to salvage good outcomes following endoscopic ethmoidectomy.

    View details for DOI 10.1016/j.otc.2010.04.010

    View details for Web of Science ID 000280482100013

    View details for PubMedID 20599089

  • The evolution of management for inverted papilloma: An analysis of 200 cases OTOLARYNGOLOGY-HEAD AND NECK SURGERY Lawson, W., Patel, Z. M. 2009; 140 (3): 330-335


    To assess the evolution of management within one institution with the largest case series and longest clinical follow-up of IP to date in the literature and to compare this management with what has been recently presented in publication.A case series was performed assessing sex, age, presenting symptoms, origin of lesion, staging, primary versus recurrence, radiographic findings, method of treatment, rate of recurrence, and associated malignancy.Two hundred patients (average age, 57) underwent endoscopic or endoscopic-assisted resection of IP. The mean follow-up was 4.3 years (range, 9 months-19 years). Eighty percent of cases over the last decade had prior surgery before presentation. Sixty-three percent were Krouse stage T3, and 25 percent were T4. Combined approaches were used for 57 percent of the most recent 40 cases, including Caldwell-Luc, lateral rhinotomy, medial maxillectomy, trephine, or osteoplastic flap.Inverted papilloma can be addressed endoscopically when possible, with data from this study and the current literature suggesting this is feasible in 43 percent to 66 percent of cases. This decision should be made for each individual case, and variables that will likely affect the decision to use adjuvant external approaches include significant scarring and anatomic distortion from previous surgery, high Krouse stage, and associated malignancy.

    View details for DOI 10.1016/j.otohns.2008.11.010

    View details for Web of Science ID 000263810600009

    View details for PubMedID 19248937

  • The Development and Pathologic Processes that Influence Maxillary Sinus Pneumatization ANATOMICAL RECORD-ADVANCES IN INTEGRATIVE ANATOMY AND EVOLUTIONARY BIOLOGY Lawson, W., Patel, Z. M., Lin, F. Y. 2008; 291 (11): 1554-1563


    The maxillary sinus is universally described as a pyramidal-shaped cavity in the maxilla. Hypoplasia, which can occur unilaterally or bilaterally, is graded by the authors by the degree of failure of descent below the nasal floor in achieving its position adjacent to the posterior dentition in the adult. Unlike early studies using plain X-rays, which considered pneumatization into the zygomatic recess and dental alveolus as criteria, the authors have adopted the above-cited parameters based on computed tomography (CT) imaging, which reveals that even when smaller the sinus retains a pyramidal configuration, although truncated. Rarely, the sinus is excessively pneumatized in the nonpathologic state. Review of the literature failed to reveal a comprehensive study of the conditions that alter maxillary sinus volume and configuration. Based on a retrospective review of 6,000 high resolution CT scans of the paranasal sinuses, the types and relative incidences of these conditions have been determined, and a classification system proposed. The mixed-sex sample group (= 2,540) was comprised of nonpediatric (adolescent and adult) and was of a polyethnic composition. Results showed that enlargement of the sinus is uncommonly encountered, and is produced by air (pneumocele) and mucus (mucocele) entrapment, or by benign tumors which have arisen in the sinus or adjacent maxilla and have grown intracavitarily, with the sinus walls expanding and remodeling to accommodate them. Reduction in size and volume is more frequent. Heredo-familial syndromic conditions reduce sinus size by impaired facial growth centers, or obliteration by dense osteosclerosis. Irradiation for neoplastic disease in the pediatric population similarly, directly effect growth centers, or impairs pituitary function. Another iatrogenic cause, direct surgical intervention (Caldwell-Luc procedure) almost universally alters sinus volume and shape by osteoneogenesis. Midfacial fractures involving the sinus also produce distortion by sclerosis as well as by malpositioning of bone fragments. The principal systemic disorders, sickle cell anemia and osteopetrosis, which diffusely effect medullary bone, do so either through compensatory marrow proliferation or sclerotic new bone formation, thus serving to produce maxillary enlargement and sinus obliteration. The greatest source of maxillary sinus distortion and destruction are neoplasms. Malignant sinonasal and oral cavity tumors produce bony erosion of the sinus walls, whereas benign odontogenic cysts remain external to the sinuses and compress it as they enlarge. Most odontogenic tumors produce external compression and remodeling. Fibro-osseous disorders similarly produce size and shape distortions by external impingement. Although diverse developmental and pathological conditions influence maxillary sinus morphology, there is a limited range of biologic response.

    View details for DOI 10.1002/ar.20774

    View details for Web of Science ID 000260396400017

    View details for PubMedID 18951496