Bio


Dr. Zara M. Patel is Director of Endoscopic Skull Base Surgery and a 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 in 2015.

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 has served as Chair of the Education Committee and Member of the Board of Directors for the American Rhinologic Society, is current Chair of the Rhinology and Allergy Education Committee for the American Academy of Otolaryngology - Head and Neck Surgery, 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 currently collaborating with neuroscientists and engineers to develop technology that she hopes will eventually help cure patients with smell loss, and potentially even help those with neurodegenerative disorders, such as Alzheimer's and Parkinson's disease.

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 Neurorhinology - Advanced Sinus and Skull Base Surgery Fellowship, Department of Otolaryngology-Head and Neck Surgery, Stanford University (2015 - Present)

Honors & Awards


  • Presidential Citation for Service, American Rhinologic Society (2018, 2021, 2022)
  • 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


  • Chair, Rhinology and Allergy Education Committee, American Academy of Otolaryngology and Head and Neck Surgery (2021 - Present)
  • Member, Board of Directors, American Rhinologic Society (2018 - 2021)
  • Member, Scientific Program Committee, American Academy of Otolaryngology (2016 - 2021)
  • 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 - 2021)
  • Member, Program Committee, American Rhinologic Society (2012 - 2016)
  • Member, Legislative Representatives Committee, Board of Governors, American Academy of Otolaryngology (2012 - 2016)

Professional Education


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

2023-24 Courses


All Publications


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

    Abstract

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

    View details for DOI 10.1002/lary.31438

    View details for PubMedID 38634358

  • Can GPT-4 revolutionize otolaryngology? Navigating opportunities and ethical considerations. American journal of otolaryngology Edalati, S., Vasan, V., Cheng, C. P., Patel, Z., Govindaraj, S., Iloreta, A. M. 2024; 45 (4): 104303

    Abstract

    Otolaryngologists can enhance workflow efficiency, provide better patient care, and advance medical research and education by integrating artificial intelligence (AI) into their practices. GPT-4 technology is a revolutionary and contemporary example of AI that may apply to otolaryngology. The knowledge of otolaryngologists should be supplemented, not replaced when using GPT-4 to make critical medical decisions and provide individualized patient care. In our thorough examination, we explore the potential uses of the groundbreaking GPT-4 technology in the field of otolaryngology, covering aspects such as potential outcomes and technical boundaries. Additionally, we delve into the intricate and intellectually challenging dilemmas that emerge when incorporating GPT-4 into otolaryngology, considering the ethical considerations inherent in its implementation. Our stance is that GPT-4 has the potential to be very helpful. Its capabilities, which include aid in clinical decision-making, patient care, and administrative job automation, present exciting possibilities for enhancing patient outcomes, boosting the efficiency of healthcare delivery, and enhancing patient experiences. Even though there are still certain obstacles and limitations, the progress made so far shows that GPT-4 can be a valuable tool for modern medicine. GPT-4 may play a more significant role in clinical practice as technology develops, helping medical professionals deliver high-quality care tailored to every patient's unique needs.

    View details for DOI 10.1016/j.amjoto.2024.104303

    View details for PubMedID 38678799

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

    Abstract

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

    View details for DOI 10.1002/alr.23351

    View details for PubMedID 38567900

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

    Abstract

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

    View details for DOI 10.1002/alr.23338

    View details for PubMedID 38372441

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

    Abstract

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

    View details for DOI 10.1002/alr.23332

    View details for PubMedID 38343143

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

    Abstract

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

    View details for DOI 10.1002/alr.23325

    View details for PubMedID 38297486

  • Ipsilateral Nasoseptal Flaps in a Transpterygoid Approach: Technical Pearls and Reconstruction Outcomes JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Chang, M. T., Grimm, D., Asmaro, K., Yong, M., Low, C., Lee, C. K., Nayak, J. V., Hwang, P. H., Fernandez-Miranda, J. C., Patel, Z. M. 2024
  • Efficacy of EDS-FLU for Chronic Rhinosinusitis: Two Randomized Controlled Trials (ReOpen1 and ReOpen2). The journal of allergy and clinical immunology. In practice Palmer, J. N., Adappa, N. D., Chandra, R. K., Davis, G. E., Mahdavinia, M., Messina, J., Ow, R. A., Patel, Z. M., Peters, A. T., Sacks, H., Schlosser, R. J., Sindwani, R., Soler, Z. M., White, A. A., Wise, S. K., Mahmoud, R. A. 2024

    Abstract

    Chronic rhinosinusitis (CRS) is a prevalent inflammatory disease. No medications are Food and Drug Administration-approved for the most common form, CRS without nasal polyps (also called "chronic sinusitis"). Novel biomechanics of the exhalation delivery system deliver fluticasone (EDS-FLU; XHANCE) to sinonasal areas above the inferior turbinate, especially sinus drainage pathways not reached by standard-delivery nasal sprays.Assess EDS-FLU efficacy for CRS (irrespective of nasal polyps).Two randomized, EDS-placebo-controlled trials in adults with CRS irrespective of polyps (ReOpen1) or exclusively without polyps (ReOpen2) were conducted at 120 sites in 13 countries. Patients received EDS-FLU 1 or 2 sprays/nostril, or EDS-placebo, twice daily for 24 weeks. Coprimary measures were composite symptom score through week 4 and ethmoid/maxillary sinus percent opacification by computed tomography at week 24.ReOpen1 (N = 332) composite symptom score least-squares mean change for EDS-FLU 1 or 2 sprays/nostril versus EDS-placebo was -1.58 and -1.60 versus -0.62 (P < .001, P < .001); ReOpen2 (N = 223), -1.54 and -1.74 versus -0.81 (P = .011, P = .001). In ReOpen1, sinus opacification least-squares mean change for EDS-FLU 1 or 2 sprays/nostril versus EDS-placebo was -5.58 and -6.20 versus -1.60 (P = .045, P = .018), and in ReOpen2, -7.00 and -5.14 versus +1.19 (P < .001, P = .009). Acute disease exacerbations were reduced by 56% to 66% with EDS-FLU versus EDS-placebo (P = .001). There were significant, and similar magnitude, symptom reductions in patients using standard-delivery nasal steroid products just before entering the study (P < .001). Adverse events were similar to standard-delivery intranasal steroids.EDS-FLU is the first nonsurgical treatment demonstrated to reduce symptoms, intrasinus opacification, and exacerbations in replicate randomized clinical trials in CRS, regardless of polyp status.

    View details for DOI 10.1016/j.jaip.2023.12.016

    View details for PubMedID 38244014

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

    Abstract

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

    View details for DOI 10.1002/alr.23312

    View details for PubMedID 38145393

  • Surgical Correction of Nasal Obstruction and Its Effect on Eustachian Tube Dysfunction Symptoms. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Daum, R., Grimm, D., Castro Silva, B. R., Huang, A. E., Lee, J. Y., Nayak, J. V., Patel, Z. M., Hwang, P. H., Chang, M. T. 2023

    Abstract

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

    View details for DOI 10.1002/ohn.607

    View details for PubMedID 38037398

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

    Abstract

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

    View details for DOI 10.1002/alr.23270

    View details for PubMedID 37725072

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

    Abstract

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

    View details for DOI 10.1002/alr.23266

    View details for PubMedID 37694445

  • Olfactory System: Basic Anatomy and Physiology for General Otorhinolaryngologists. Clinical and experimental otorhinolaryngology Han, S. A., Kim, J. K., Cho, D., Patel, Z. M., Rhee, C. 2023

    Abstract

    Olfaction is one of the five basic human senses, and it is known to be one of the most primitive senses. The sense of olfaction may have been critical for human survival in prehistoric society, and although many believe its importance has diminished over time, its impact on human interaction, bonding, and propagation of the species remains. Even if we are unaware of it, the sense of smell greatly affects our lives. Sense of smell is closely related to overall quality of life and health. However, olfaction has been neglected from a scientific perspective compared to other senses. Olfaction has recently received substantial attention since the loss of smell and taste has been noted as a key symptom of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Studies investigating olfaction loss in association with coronavirus disease 2019 (COVID-19) have revealed that olfactory dysfunction can be both conductive and sensorineural, possibly causing structural changes in the brain. Olfactory training is one of the effective treatments for olfactory dysfunction, suggesting the reorganization of neural associations. Reduced ability to smell may also alert suspicion for neurodegenerative or psychiatric disorders. Here, we summarize the basic knowledge that we, as otorhinolaryngologists, should have about the sense of smell and the peripheral and central olfactory pathway for managing and helping patients with olfactory dysfunction.

    View details for DOI 10.21053/ceo.2023.00185

    View details for PubMedID 37669740

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

    Abstract

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

    View details for DOI 10.1002/alr.23262

    View details for PubMedID 37658764

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

    Abstract

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

    View details for DOI 10.1002/alr.23261

    View details for PubMedID 37646428

  • A Consistent Endoscopic Landmark to Identify the Anterior Ethmoidal Artery. The Laryngoscope Mundy, D. C., Yan, C. H., Tyler, M. A., Patel, Z. M. 2023

    Abstract

    OBJECTIVE: The anterior ethmoidal artery (AEA) is an important structure to identify during endoscopic sinus surgery. Although identification on imaging is easily taught, a consistent endoscopic landmark for the AEA, independent of anatomic ethmoid cell variation, is lacking, leaving many surgeons unclear about the exact location without dependence on navigation. Here, we describe a consistent endoscopic landmark, regardless of anatomical ethmoid variation.METHODS: We prospectively enrolled adult patients undergoing endoscopic surgery involving frontal and ethmoid sinuses in this observational study. The AEA landmark was defined simply as the septation or ridge one step back along the ethmoid skull base from the posterior table of the frontal sinus. The gold standard to calculate the sensitivity of our endoscopic landmark was an image-navigation system, registered to within 1.5mm accuracy, locating the AEA within three planes. Both endoscopic and computerized tomography (CT) images of the pointer at the landmark were taken simultaneously. The concordance of endoscopic to navigation images was independently assessed by three blinded rhinologists.RESULTS: Forty patients were included in our study with 73 sides analyzed. Diagnoses included chronic rhinosinusitis without polyps (52.5%), with polyps (22.5%), recurrent acute sinusitis (15%), sinonasal tumors (7.5%), and odontogenic sinusitis (2.5%). The AEA was accurately identified using our endoscopic landmark in 97.3% of the cases (71/73). Of the two cases in which the AEA was not found within the landmark, the artery was located ≤1mm posteriorly.CONCLUSION: We describe a consistent endoscopic landmark to identify the AEA, conserved across various clinical diagnoses and anatomic variations in sinus structure.LEVEL OF EVIDENCE: 3 Laryngoscope, 2023.

    View details for DOI 10.1002/lary.30963

    View details for PubMedID 37578267

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

    Abstract

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

    View details for DOI 10.1001/jamaoto.2023.1939

    View details for PubMedID 37535372

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

    Abstract

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

    View details for DOI 10.1055/s-0042-1750178

    View details for PubMedID 37405239

    View details for PubMedCentralID PMC10317567

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

    Abstract

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

    View details for DOI 10.1002/alr.23227

    View details for PubMedID 37389470

  • Long-term quality of life after treatment in sinonasal malignancy: A prospective, multi-center study. International forum of allergy & rhinology Maoz, S. L., Wang, E. W., Hwang, P. H., Choby, G., Kuan, E. C., Fleseriu, C. M., Chan, E. P., Adappa, N. D., Geltzeiler, M., Getz, A. E., Humphreys, I. M., Le, C. H., Abuzeid, W. M., Chang, E. H., Jafari, A., Kingdom, T. T., Kohanski, M. A., Lee, J. K., Lazor, J. W., Nabavizadeh, A., Nayak, J. V., Palmer, J. N., Patel, Z. M., Pinheiro-Neto, C. D., Resnick, A. C., Smith, T. L., Snyderman, C. H., St John, M. A., Storm, P. B., Suh, J. D., Wang, M. B., Sim, M. S., Beswick, D. M. 2023

    Abstract

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

    View details for DOI 10.1002/alr.23171

    View details for PubMedID 37082883

  • Disparities in Access to Healthcare in Adults with Sinusitis in the United States. International forum of allergy & rhinology Shah, J. P., Youn, G. M., Wei, E. X., Patel, Z. M. 2023

    Abstract

    Sinusitis can significantly decrease quality of life, is costly in both healthcare expenditure and lost productivity, and can lead to complications if treatment is delayed. Our objective was to explore disparities in healthcare access among adults with sinusitis based on sociodemographic factors.32,994 participants (representing 244,838,261 U.S. adults) who completed the 2016 National Health Interview Survey were analyzed, of which 12.17% were diagnosed with sinusitis at least once in the prior 12 months. Multivariate regression analyses were performed.In regression analyses, female sex (OR = 2.00; [95% CI, 1.79-2.24]; p<0.001) and older age groups were associated with increased odds of having sinusitis. Within the sinusitis cohort, Asian race (OR = 5.97; [1.61-22.12]; p = 0.008) and Hispanic ethnicity (OR = 6.97; [3.22-15.06]; p<0.001) were associated with increased odds of obtaining foreign medications. Individuals with Medicaid had decreased odds of delaying care (OR = 0.37; [0.25-0.56]; p<0.001) or not receiving care due to cost (OR = 0.40; [0.24-0.65]; p<0.001), but increased odds of delaying care due to transportation barriers (OR = 4.64; [2.52-8.55]; p<0.001). Uninsured individuals had higher odds for delaying care (OR = 4.97; [3.35-7.38]; p<0.001) and not receiving care (OR = 5.46; [3.56-8.38]; p<0.001) due to cost. Income > $100,000 was associated with a nearly 90% reduction in inability to obtain care due to cost (OR = 0.11; [0.05-0.21]; p-value<0.001) and an over 99% reduction in inability to obtain care due to transportation issues compared to income < $35,000 (OR = 0.01; [0.00-0.04]; p-value<0.001).Significant disparities in healthcare access based on race, health insurance status, and income exist among adults with sinusitis in the United States. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23167

    View details for PubMedID 37029607

  • The Utility of a "Second-Look" Debridement Following Endonasal Skull Base Surgery in the Pediatric Population JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Chang, M. T., Huang, A. E., Quon, J. L., Fernandez-Miranda, J. C., Wen, C. Z., Eide, J. G., Kshirsagar, R. S., Qian, Z., Nayak, J. V., Hwang, P. H., Adappa, N. D., Patel, Z. M. 2023
  • Nasal disease with polyps: need for clarity. International forum of allergy & rhinology Pezato, R., Stamm, A. C., Douglas, R., Han, J. K., Chen, P. G., Neto, C. D., Tepedino, M. S., Singh, N., Balsalobre, L., Ryu, C. H., Gregorio, L., Amatrafi, S., Felippu, A. W., Iturriaga, E., Toledo, R. N., Cascio, F., Dassi, C., Alkholaiwi, F., Bezerra, T. F., Javer, A., Dutra, D. L., Psaltis, A. J., Migueis, D. P., Almutari, N., Avelino, M. A., Gunaratne, D. A., Felippu, A., Pinna, F. d., Nakanishi, M., Perez-Novo, C. A., Singhera, G. K., Choby, G., Wang, E. W., Patel, Z. M., Thamboo, A. 2023

    View details for DOI 10.1002/alr.23150

    View details for PubMedID 36869634

  • Radiographic predictors of occult intracranial involvement in olfactory neuroblastoma patients. International forum of allergy & rhinology Geltzeiler, M., Choby, G. W., Ji, K. S., Mace, J. C., Almeida, J. P., de Almeida, J., Champagne, P., Chan, E., Ciporen, J. N., Chaskes, M. B., Cornell, S., Drozdowski, V., Fernandez-Miranda, J., Gardner, P. A., Hwang, P. H., Kalyvas, A., Kong, K. A., McMillan, R. A., Nayak, J. V., Patel, C., Patel, Z. M., Celda, M. P., Pinheiro-Neto, C., Sanusi, O. R., Snyderman, C. H., Thorp, B. D., Van Gompel, J. J., Zadeh, G., Zenonos, G., Zwagerman, N. T., Wang, E. W. 2023

    Abstract

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

    View details for DOI 10.1002/alr.23145

    View details for PubMedID 36841933

  • Myalgic Encephalomyelitis/Chronic Fatigue Syndrome is common in post-acute sequelae of SARS-CoV-2 infection (PASC): Results from a post-COVID-19 multidisciplinary clinic. Frontiers in neurology Bonilla, H., Quach, T. C., Tiwari, A., Bonilla, A. E., Miglis, M., Yang, P. C., Eggert, L. E., Sharifi, H., Horomanski, A., Subramanian, A., Smirnoff, L., Simpson, N., Halawi, H., Sum-Ping, O., Kalinowski, A., Patel, Z. M., Shafer, R. W., Geng, L. C. 2023; 14: 1090747

    Abstract

    The global prevalence of PASC is estimated to be present in 0·43 and based on the WHO estimation of 470 million worldwide COVID-19 infections, corresponds to around 200 million people experiencing long COVID symptoms. Despite this, its clinical features are not well-defined.We collected retrospective data from 140 patients with PASC in a post-COVID-19 clinic on demographics, risk factors, illness severity (graded as one-mild to five-severe), functional status, and 29 symptoms and principal component symptoms cluster analysis. The Institute of Medicine (IOM) 2015 criteria were used to determine the Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) phenotype.The median age was 47 years, 59.0% were female; 49.3% White, 17.2% Hispanic, 14.9% Asian, and 6.7% Black. Only 12.7% required hospitalization. Seventy-two (53.5%) patients had no known comorbid conditions. Forty-five (33.9%) were significantly debilitated. The median duration of symptoms was 285.5 days, and the number of symptoms was 12. The most common symptoms were fatigue (86.5%), post-exertional malaise (82.8%), brain fog (81.2%), unrefreshing sleep (76.7%), and lethargy (74.6%). Forty-three percent fit the criteria for ME/CFS, majority were female, and obesity (BMI > 30 Kg/m2) (P = 0.00377895) and worse functional status (P = 0.0110474) were significantly associated with ME/CFS.Most PASC patients evaluated at our clinic had no comorbid condition and were not hospitalized for acute COVID-19. One-third of patients experienced a severe decline in their functional status. About 43% had the ME/CFS subtype.

    View details for DOI 10.3389/fneur.2023.1090747

    View details for PubMedID 36908615

    View details for PubMedCentralID PMC9998690

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

    Abstract

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

    View details for DOI 10.1002/lary.30619

    View details for PubMedID 36807152

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

    Abstract

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

    View details for DOI 10.1002/alr.23127

    View details for PubMedID 36608352

  • Avoiding bias in artificial intelligence. International forum of allergy & rhinology Gudis, D. A., McCoul, E. D., Marino, M. J., Patel, Z. M. 2022

    Abstract

    Artificial intelligence (AI) is ubiquitous and expanding, and the healthcare industry has rapidly adopted AI and machine learning for numerous applications. It is essential to understand that AI is not immune to the biases that impact our clinical and academic work, and in fact may inadvertently amplify rather than reduce them. As we harness the power of AI, it is our obligation to our patients to ensure that we address these concerns. We must take responsibility for proactive stewardship to protect against bias, not only for new AI algorithms, but also for our research studies that may one day provide data for those algorithms. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23129

    View details for PubMedID 36573806

  • Use of platelet-rich plasma for COVID-19 related olfactory loss, a randomized controlled trial. International forum of allergy & rhinology Yan, C. H., Jang, S. S., Lin, H. C., Ma, Y., Khanwalker, A. R., Thai, A., Patel, Z. M. 2022

    Abstract

    This study evaluated the use of platelet-rich plasma (PRP), an autologous blood product with supraphysiologic concentrations of growth factors, in the treatment of prolonged COVID-19 related smell loss.This multi-institutional, randomized controlled trial recruited COVID-19 patients with objectively measured smell loss (University of Pennsylvania's Smell Identification Test, UPSIT≤33) between 6-12 months. Subjects were randomized to 3 intranasal injections of either PRP or sterile saline into their olfactory clefts. Primary outcome measure was change in Sniffin' sticks score (TDI) from baseline. Secondary endpoint measures included responder rate (achievement of a clinically significant improvement, ≥5.5 point TDI), change in individual TDI olfaction scores, and change in subjective olfaction via a visual analogue scale.35 subjects were recruited and 26 completed the study. PRP treatment resulted in a 3.67 point (95% CI: 0.05-7.29, p = 0.047) greater improvement in olfaction compared to the placebo group at 3-months and a higher response rate (57.1% versus 8.3%, odds ratio 12.5, 95% exact bootstrap CI 2.2-116.7). There was a greater improvement in smell discrimination following PRP treatment compared to placebo, but no difference in smell identification or threshold. There was no difference in subjective scores between PRP and placebo. No adverse effects were reported.Olfactory function following COVID-19 can improve spontaneously after 6 months and can improve to a greater extent with PRP injection. This data builds on the promise of PRP to be a safe potential treatment option for patients with COVID-19 smell loss, and larger-powered studies will help further assess efficacy. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.23116

    View details for PubMedID 36507615

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

    View details for DOI 10.1002/alr.23100

    View details for PubMedID 36409559

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

    View details for DOI 10.1002/alr.23110

    View details for PubMedID 36399364

  • Novel Therapies in Olfactory Disorders CURRENT OTORHINOLARYNGOLOGY REPORTS Chang, M. T., Patel, Z. M. 2022: 1-6

    Abstract

    To summarize and critically review the recent literature on novel treatments for olfactory disorders (OD).Emerging therapies in the management of OD include multiple vitamins and supplements, biologics, neuromodulators, and intranasal agents. There is also an active investigation into treatments that harness the neuroregenerative properties of the olfactory epithelium, such as platelet-rich plasma and stem cell transplantation.Successful management of OD is multimodal and tailored to the underlying etiology. As the findings of further investigations accrue, the management of OD will undoubtedly continue to be advanced and refined, and likely harness the intrinsic neuroregenerative properties of the olfactory system.

    View details for DOI 10.1007/s40136-022-00436-z

    View details for Web of Science ID 000870932400001

    View details for PubMedID 36312744

    View details for PubMedCentralID PMC9589531

  • The Omicron Variant of SARS-CoV-2 and its Effect on the Olfactory System. International forum of allergy & rhinology Dehgani-Mobaraki, P., Patel, Z., Zaidi, A. K., Giannandrea, D., Hopkins, C. 2022

    View details for DOI 10.1002/alr.23089

    View details for PubMedID 36103157

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

    Abstract

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

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

    View details for PubMedID 35705579

  • International consensus statement on allergy and rhinology: Olfaction. International forum of allergy & rhinology Patel, Z. M., Holbrook, E. H., Turner, J. H., Adappa, N. D., Albers, M. W., Altundag, A., Appenzeller, S., Costanzo, R. M., Croy, I., Davis, G. E., Dehgani-Mobaraki, P., Doty, R. L., Duffy, V. B., Goldstein, B. J., Gudis, D. A., Haehner, A., Higgins, T. S., Hopkins, C., Huart, C., Hummel, T., Jitaroon, K., Kern, R. C., Khanwalkar, A. R., Kobayashi, M., Kondo, K., Lane, A. P., Lechner, M., Leopold, D. A., Levy, J. M., Marmura, M. J., Mclelland, L., Miwa, T., Moberg, P. J., Mueller, C. A., Nigwekar, S. U., O'Brien, E. K., Paunescu, T. G., Pellegrino, R., Philpott, C., Pinto, J. M., Reiter, E. R., Roalf, D. R., Rowan, N. R., Schlosser, R. J., Schwob, J., Seiden, A. M., Smith, T. L., Soler, Z. M., Sowerby, L., Tan, B. K., Thamboo, A., Wrobel, B., Yan, C. H. 2022; 12 (4): 327-680

    Abstract

    BACKGROUND: The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O).METHODS: Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus.RESULTS: The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies.CONCLUSION: This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

    View details for DOI 10.1002/alr.22929

    View details for PubMedID 35373533

  • Anatomic Considerations in Endoscopic Pituitary Surgery. Otolaryngologic clinics of North America Low, C. M., Vigo, V., Nunez, M., Fernandez-Miranda, J. C., Patel, Z. M. 2022

    Abstract

    The pituitary gland is a small gland at the base of the skull controlling many physiologic processes through its regulation of primary endocrine glands. Pathologies of the pituitary gland and sellar space are wide ranging and most commonly include pituitary adenomas but can also encompass pituitary hyperplasia, other benign nonadenomatous tumors, cysts, and primary and metastatic malignancy. At present, the endoscopic approach has been established as a safe and effective approach to surgical management of pituitary pathology. A detailed understanding of the sella and parasellar anatomy from an endoscopic approach is imperative to performing safe endoscopic surgery in this area.

    View details for DOI 10.1016/j.otc.2021.12.014

    View details for PubMedID 35256171

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

    Abstract

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

    View details for DOI 10.1002/alr.22958

    View details for PubMedID 34989484

  • Association of Race, Ethnicity, and Socioeconomic Status With Esthesioneuroblastoma Presentation, Treatment, and Survival. OTO open Sharma, R. K., Irace, A. L., Overdevest, J. B., Turner, J. H., Patel, Z. M., Gudis, D. A. 2022; 6 (1): 2473974X221075210

    Abstract

    Objective: Socioeconomic and other demographic factors are associated with outcomes in head and neck cancer. This study uses a national cancer database to explore how patient race, ethnicity, and socioeconomic status (SES) are associated with esthesioneuroblastoma outcomes, including 5-year disease-specific survival (DSS), conditional DSS, stage at diagnosis, and treatment.Study Design: Retrospective cohort analysis.Setting: Patients with esthesioneuroblastomas between 1973 and 2015 from the SEER registry (Surveillance, Epidemiology, and End Results).Methods: The National Cancer Institute Yost Index, a census tract-level composite score composed of 7 parameters, was used to categorize the SES of patients. Kaplan-Meier analysis and Cox regression were conducted to assess DSS. Conditional DSS was calculated per estimates from simplified Cox models. Logistic regression was conducted to identify risk factors for advanced cancer stage at diagnosis and the likelihood of receiving multimodal therapy.Results: Complete data were included for 561 patients. DSS was significantly associated with SES (log-rank, P < .01) but not race. According to Cox regression, DSS was worse for the lowest SES tertile vs the highest (hazard ratio, 1.70 [95% CI, 1.05-2.75]; P = .03). Patients of the lowest SES tertile exhibited an increased risk of advanced cancer stage at diagnosis as compared with the highest SES tertile (odds ratio, 1.84 [95% CI, 1.06-3.30]; P = .035). Black patients (odds ratio, 0.44 [95% CI, 0.24-0.84]; P = .011) were less likely than other patients to receive multimodal therapy. SES alone was not associated with receiving multimodal therapy.Conclusion: SES is significantly associated with DSS and conditional DSS for patients with esthesioneuroblastomas. Inequalities in access to care and treatment likely contribute to these disparities.

    View details for DOI 10.1177/2473974X221075210

    View details for PubMedID 35174302

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

    Abstract

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

    View details for DOI 10.1016/j.ejca.2021.09.046

    View details for PubMedID 34980502

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

    Abstract

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

    View details for DOI 10.1002/alr.22943

    View details for PubMedID 34894093

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

    Abstract

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

    View details for DOI 10.1002/alr.22935

    View details for PubMedID 34875144

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

    Abstract

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

    View details for DOI 10.1016/j.jaci.2021.11.017

    View details for PubMedID 34863854

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

    Abstract

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

    View details for DOI 10.1002/lary.29935

    View details for PubMedID 34724213

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

    Abstract

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

    View details for DOI 10.1016/j.xcrm.2021.100421

    View details for PubMedID 34604819

  • Emerging concepts in endoscopic skull base surgery training. International forum of allergy & rhinology Choby, G., Rabinowitz, M. R., Patel, Z. M., McKinney, K. A., Del Signore, A. G., Ebert, C. S., Thorp, B. D., Wang, E. W. 2021

    View details for DOI 10.1002/alr.22895

    View details for PubMedID 34569168

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

    Abstract

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

    View details for DOI 10.1001/jamaoto.2021.1839

    View details for PubMedID 34351376

  • Olfactory Loss and Olfactory Training. JAMA otolaryngology-- head & neck surgery Patel, Z. M. 2021

    View details for DOI 10.1001/jamaoto.2021.1507

    View details for PubMedID 34264287

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

    Abstract

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

    View details for DOI 10.1002/alr.22833

    View details for PubMedID 34176231

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

    Abstract

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

    View details for DOI 10.1001/jamaoto.2021.0011

    View details for PubMedID 33662124

  • Corrigendum to: More Than Smell-COVID-19 Is Associated With Severe Impairment of Smell, Taste, and Chemesthesis. Chemical senses Parma, V., Ohla, K., Veldhuizen, M. G., Niv, M. Y., Kelly, C. E., Bakke, A. J., Cooper, K. W., Bouysset, C., Pirastu, N., Dibattista, M., Kaur, R., Liuzza, M. T., Pepino, M. Y., Schopf, V., Pereda-Loth, V., Olsson, S. B., Gerkin, R. C., Rohlfs Dominguez, P., Albayay, J., Farruggia, M. C., Bhutani, S., Fjaeldstad, A. W., Kumar, R., Menini, A., Bensafi, M., Sandell, M., Konstantinidis, I., Di Pizio, A., Genovese, F., Ozturk, L., Thomas-Danguin, T., Frasnelli, J., Boesveldt, S., Saatci, O., Saraiva, L. R., Lin, C., Golebiowski, J., Hwang, L., Ozdener, M. H., Guardia, M. D., Laudamiel, C., Ritchie, M., Havlicek, J., Pierron, D., Roura, E., Navarro, M., Nolden, A. A., Lim, J., Whitcroft, K. L., Colquitt, L. R., Ferdenzi, C., Brindha, E. V., Altundag, A., Macchi, A., Nunez-Parra, A., Patel, Z. M., Fiorucci, S., Philpott, C. M., Smith, B. C., Lundstrom, J. N., Mucignat, C., Parker, J. K., van den Brink, M., Schmuker, M., Fischmeister, F. P., Heinbockel, T., Shields, V. D., Faraji, F., Santamaria, E., Fredborg, W. E., Morini, G., Olofsson, J. K., Jalessi, M., Karni, N., D'Errico, A., Alizadeh, R., Pellegrino, R., Meyer, P., Huart, C., Chen, B., Soler, G. M., Alwashahi, M. K., Welge-Lussen, A., Freiherr, J., de Groot, J. H., Klein, H., Okamoto, M., Singh, P. B., Hsieh, J. W., GCCR Group Author, Reed, D. R., Hummel, T., Munger, S. D., Hayes, J. E., Abdulrahman, O., Dalton, P., Yan, C. H., Voznessenskaya, V. V., Chen, J., Sell, E. A., Walsh-Messinger, J., Archer, N. S., Koyama, S., Deary, V., Roberts, S. C., Yanik, H., Albayrak, S., Novakova, L. M., Croijmans, I., Mazal, P. P., Moein, S. T., Margulis, E., Mignot, C., Marino, S., Georgiev, D., Kaushik, P. K., Malnic, B., Wang, H., Seyed-Allaei, S., Yoluk, N., Razzaghi-Asl, S., Justice, J. M., Restrepo, D. 2021; 46

    View details for DOI 10.1093/chemse/bjab050

    View details for PubMedID 34879393

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

    Abstract

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

    View details for DOI 10.1002/alr.22741

    View details for PubMedID 33236525

  • Regarding Use of Topical Steroids in Patients With COVID-19-Associated Olfactory Loss. JAMA otolaryngology-- head & neck surgery Patel, Z. M. 2020

    View details for DOI 10.1001/jamaoto.2020.4275

    View details for PubMedID 33211102

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

    Abstract

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

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

    View details for PubMedID 33116139

  • Risk Factors for Rhinosinusitis After Endoscopic Transsphenoidal Adenomectomy. American journal of rhinology & allergy Lee, C. H., Ikeda, A. K., Patel, S., Levy, J. M., Patel, Z. M., Arturo Solares, C., Oyesiku, N., Wise, S. K. 2020: 1945892420958549

    Abstract

    OBJECTIVE: Patients undergoing endoscopic transsphenoidal adenomectomy (eTSA) for pituitary tumors are at risk for postoperative complications, including rhinosinusitis. We aimed to determine if preoperative sinonasal disease is a risk factor for postoperative rhinosinusitis (PRS).STUDY DESIGN: Retrospective review.SETTING: Tertiary academic center in U.S.SUBJECTS AND METHODS: Patients with a diagnosis of pituitary adenoma who underwent eTSA between 2007-2016. PRS patients were matched to non-PRS patients or sex, age, tumor size, skull base reconstruction with intranasal tissue grafting, and concurrent septoplasty. Groups were statistically analyzed for potential preoperative risk factors of sinonasal disease (patient-reported, radiographic, endoscopic).RESULTS: 49 of 987 patients who underwent eTSA developed PRS (44.9% male, 71.4% Caucasian, mean age 49.3y). On analysis of individual risk factors, there was a significantly higher proportion of patients with a history of prior sinonasal surgery in the PRS group than the non-PRS group (25.5% vs. 6.5%, p=0.01); however, this group difference became insignificant on multivariate analysis. There were no significant group differences with regard to history of sinus infections, nasal symptoms, seasonal allergies, radiographic abnormalities, or sinonasal disease on endoscopy.CONCLUSION: This is the first study to investigate preoperative sinonasal disease as a risk factor for PRS after eTSA. The risk factors considered did not demonstrate definitive risk for PRS, although a history of prior sinonasal surgery should be investigated further.

    View details for DOI 10.1177/1945892420958549

    View details for PubMedID 32921135

  • Reply to: Correspondence - International Registry of Otolaryngologist - Head and Neck Surgeons with COVID-19. International forum of allergy & rhinology Sowerby, L. J., Patel, Z. M. 2020

    View details for DOI 10.1002/alr.22689

    View details for PubMedID 32827240

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

    Abstract

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

    View details for DOI 10.1177/1945892420947932

    View details for PubMedID 32746611

  • In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic NEUROSURGERY Patel, Z. M., Fernandez-Miranda, J., Hwang, P. H., Nayak, J. V., Dodd, R. L., Sajjadi, H., Jackler, R. K. 2020; 87 (2): E162–E163
  • Sinus Headache: Differential Diagnosis and an Evidence-Based Approach. Otolaryngologic clinics of North America Kim, R., Patel, Z. M. 2020

    Abstract

    The diagnosis "sinus headache" has been reclassified as "headache attributed to disorder of the nose or paranasal sinuses" by the International Headache Society, but the term is still commonly used by patients and primary care doctors alike. Rhinologic symptoms and headache disorders are common, and they may coexist without a causative relationship. Patients may undergo unnecessary medical interventions because of inadequate understanding of the classifications and management of various headache disorders. Otolaryngologists frequently treat patients with these complaints, and a systematic approach to the differential diagnosis and utilization of a multidisciplinary approach are critical in providing optimal patient care.

    View details for DOI 10.1016/j.otc.2020.05.019

    View details for PubMedID 32703695

  • More than smell - COVID-19 is associated with severe impairment of smell, taste, and chemesthesis. Chemical senses Parma, V., Ohla, K., Veldhuizen, M. G., Niv, M. Y., Kelly, C. E., Bakke, A. J., Cooper, K. W., Bouysset, C., Pirastu, N., Dibattista, M., Kaur, R., Liuzza, M. T., Pepino, M. Y., Schopf, V., Pereda-Loth, V., Olsson, S. B., Gerkin, R. C., Rohlfs Dominguez, P., Albayay, J., Farruggia, M. C., Bhutani, S., Fjaeldstad, A. W., Kumar, R., Menini, A., Bensafi, M., Sandell, M., Konstantinidis, I., Di Pizio, A., Genovese, F., Ozturk, L., Thomas-Danguin, T., Frasnelli, J., Boesveldt, S., Saatci, O., Saraiva, L. R., Lin, C., Golebiowski, J., Dar Hwang, L., Ozdener, M. H., Guardia, M. D., Laudamiel, C., Ritchie, M., Havlicek, J., Pierron, D., Roura, E., Navarro, M., Nolden, A. A., Lim, J., Whitcroft, K. L., Colquitt, L. R., Ferdenzi, C., Brindha, E. V., Altundag, A., Macchi, A., Nunez-Parra, A., Patel, Z. M., Fiorucci, S., Philpott, C. M., Smith, B. C., Lundstrom, J. N., Mucignat, C., Parker, J. K., van den Brink, M., Schmuker, M., Fischmeister, F. P., Heinbockel, T., Shields, V. D., Faraji, F., Santamaria, E., Fredborg, W. E., Morini, G., Olofsson, J. K., Jalessi, M., Karni, N., D'Errico, A., Alizadeh, R., Pellegrino, R., Meyer, P., Huart, C., Chen, B., Soler, G. M., Alwashahi, M. K., Welge-Lussen, A., Freiherr, J., de Groot, J. H., Klein, H., Okamoto, M., Singh, P. B., Hsieh, J. W., Reed, D. R., Hummel, T., Munger, S. D., Hayes, J. E., GCCR Group Author, Abdulrahman, O., Dalton, P., Yan, C. H., Voznessenskaya, V. V., Chen, J., Sell, E. A., Walsh-Messinger, J., Archer, N. S., Koyama, S., Deary, V., Roberts, S. C., Yanik, H., Albayrak, S., Novakova, L. M., Croijmans, I., Mazal, P. P., Moein, S. T., Margulis, E., Mignot, C., Marino, S., Georgiev, D., Kaushik, P. K., Malnic, B., Wang, H., Seyed-Allaei, S., Yoluk, N., Razzaghi-Asl, S., Justice, J. M., Restrepo, D. 2020

    Abstract

    Recent anecdotal and scientific reports have provided evidence of a link between COVID-19 and chemosensory impairments such as anosmia. However, these reports have downplayed or failed to distinguish potential effects on taste, ignored chemesthesis, and generally lacked quantitative measurements. Here, we report the development, implementation and initial results of a multi-lingual, international questionnaire to assess self-reported quantity and quality of perception in three distinct chemosensory modalities (smell, taste, and chemesthesis) before and during COVID-19. In the first 11 days after questionnaire launch, 4039 participants (2913 women, 1118 men, 8 other, ages 19-79) reported a COVID-19 diagnosis either via laboratory tests or clinical assessment. Importantly, smell, taste and chemesthetic function were each significantly reduced compared to their status before the disease. Difference scores (maximum possible change ±100) revealed a mean reduction of smell (-79.7 ± 28.7, mean ± SD), taste (-69.0 ± 32.6), and chemesthetic (-37.3 ± 36.2) function during COVID-19. Qualitative changes in olfactory ability (parosmia and phantosmia) were relatively rare and correlated with smell loss. Importantly, perceived nasal obstruction did not account for smell loss. Furthermore, chemosensory impairments were similar between participants in the laboratory test and clinical assessment groups. These results show that COVID-19-associated chemosensory impairment is not limited to smell, but also affects taste and chemesthesis. The multimodal impact of COVID-19 and lack of perceived nasal obstruction suggest that SARS-CoV-2 infection may disrupt sensory-neural mechanisms.

    View details for DOI 10.1093/chemse/bjaa041

    View details for PubMedID 32564071

  • In Response to COVID-19 and the Otolaryngologist: Preliminary Evidence-Based Review. The Laryngoscope Vukkadala, N., Rosenthal, E., Patel, Z. M. 2020

    View details for DOI 10.1002/lary.28770

    View details for PubMedID 32484933

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

    View details for DOI 10.1093/neuros/nyaa156

    View details for PubMedID 32323725

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

    View details for DOI 10.1093/neuros/nyaa125

    View details for PubMedID 32293678

  • A primer on viral-associated olfactory loss in the era of COVID-19. International forum of allergy & rhinology Soler, Z. M., Patel, Z. M., Turner, J. H., Holbrook, E. H. 2020

    Abstract

    Early reports have suggested that smell loss may be an early symptom associated with the pandemic known as COVID-19. The possibility that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might cause olfactory dysfunction is certainly plausible. Patients presenting to specialized smell clinics are commonly diagnosed with upper respiratory infection (URI)-associated olfactory loss and most are presumed to be viral related. In acute phases of infection, it is common to experience some smell loss as a result of nasal inflammation, mucosal edema, and obstruction of airflow into the olfactory cleft. In most cases, these episodes of smell loss are self-limiting and coincide with resolution of URI symptoms. However, in some cases the smell loss persists for months to years and this is presumed to occur through a more direct olfactory insult by the virus. It remains too early to know whether infection with SARS-CoV-2 causes persistent olfactory dysfunction. However, given the scale of this pandemic, if SARS-CoV-2 does cause chronic olfactory loss in even a small portion of those infected, then the overall population prevalence could be quite large. This review provides a brief, practical overview of viral-associated olfactory loss, realizing that evidence related to COVID-19 will likely not be clear for some time. Our goal is to highlight the existence and importance of this condition and provide information geared for both providers and patients. Practical suggestions regarding evaluation and treatment will be provided, realizing that there may be constraints on medical resources and the nature of this pandemic remains dynamic. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22578

    View details for PubMedID 32271490

  • Evaluation of the Incidence of Other Cranial Neuropathies in Patients With Postviral Olfactory Loss. JAMA otolaryngology-- head & neck surgery Jitaroon, K., Wangworawut, Y., Ma, Y., Patel, Z. M. 2020

    Abstract

    Importance: Postviral olfactory loss is a common cause of olfactory impairment, affecting both quality of life as well as overall patient mortality. It is currently unclear why some patients are able to recover fully after a loss while others experience permanent deficit. There is a lack of research on the possible association between postviral olfactory loss and other cranial neuropathies.Objective: To evaluate the incidence of other cranial nerve deficits in patients with postviral olfactory loss and determine if there is an association with neurologic injury in this group. This study also sought to determine if other known risk factors were associated with postviral olfactory loss.Design, Setting, and Participants: A case-control study was conducted at a tertiary care rhinology clinic from January 2015 to January 2018 to review the incidence of cranial neuropathies in 2 groups of patients, those with postviral olfactory loss and those with chronic rhinosinusitis without olfactory loss used as a control group.Exposures: The Stanford Translational Research Integrated Database Environment (STRIDE) system was used for patient identification and data extraction. Patients with a history of olfactory loss or chronic rhinosinusitis as well as incidence of cranial neuropathies were identified by using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes.Main Outcomes and Measures: This study reviewed incidence of postviral or idiopathic cranial neuropathies in both patient groups, while also evaluating for any difference in demographic characteristics, comorbidities, or other patient-related factors.Results: There were 91 patients in the postviral olfactory loss group and 100 patients in the control group, which were age and sex matched as closely as possible. Of the 91 patients with postviral olfactory loss, mean (SD) age was 56.8 (15.3), and 58 (64%) were women; for the control group, the mean (SD) age was 57.5 (15.6) years, and 63 (63%) were women. Racial breakdown was similar across cases and controls, with white individuals making up 59% to 65%; Asian individuals, 20% to 24%; black individuals, approximately 3%; Hispanic individuals, approximately 1%; and the remaining patients being of other race/ethnicity. The incidence of other cranial neuropathies in the postviral olfactory loss group was 11% compared with 2% within the control group (odds ratio, 6.1; 95% CI, 1.3-28.4). The study also found 2 cases of multiple cranial neuropathies within a single patient within the olfactory group. Family history of neurologic disease was associated with more than 2-fold greater odds of cranial nerve deficit (odds ratio, 3.05; 95% CI, 0.59-15.68).Conclusions and Relevance: Postviral olfactory loss appears to be associated with a higher incidence of other cranial neuropathies. It is possible that there is an inherent vulnerability to nerve damage or decreased ability for nerve recovery in patients who experience this disease process.

    View details for DOI 10.1001/jamaoto.2020.0225

    View details for PubMedID 32239202

  • The use of platelet-rich plasma in treatment of olfactory dysfunction: A pilot study. Laryngoscope investigative otolaryngology Yan, C. H., Mundy, D. C., Patel, Z. M. 2020; 5 (2): 187-193

    Abstract

    Olfactory dysfunction is a prevalent problem with a significant impact on quality of life and increased mortality. Limited effective therapies exist. Platelet-rich plasma (PRP) is an autologous biologic product with anti-inflammatory and neuroprotective effects. This novel pilot study evaluated the role of PRP on olfactory neuroregeneration in patients with hyposmia.Seven patients who had olfactory loss greater than 6 months in duration, no evidence of sinonasal inflammatory disease, and no improvement with olfactory training and budesonide topical rinses were enrolled in this preliminary study. Patients received a single intranasal injection of PRP into the mucosa of the olfactory cleft. The Sniffin' Sticks olfactory test consisting of threshold, discrimination, and identification measurements (TDI) was administered at the beginning of the study and at 1 and 3 months.All patients reported a subjective improvement of their smell shortly after injection but then stabilized. At 3-month post-treatment, two patients with functional anosmia (TDI < 16) did not improve significantly. Five patients with hyposmia (TDI > 16 but <30) showed an improvement with 60% achieving normosmia (TDI > 30) at 3-month follow-up. On average, patients with baseline TDI > 16 improved by 5.85 points with the most significant improvement in the threshold subcomponent. There were no adverse outcomes from intranasal PRP injections.PRP appears safe for use in the treatment of olfactory loss, and preliminary data suggest possible efficacy, especially for those with moderate yet persistent loss. Further studies will help determine optimal frequency and duration of use.

    View details for DOI 10.1002/lio2.357

    View details for PubMedID 32337347

    View details for PubMedCentralID PMC7178450

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

    View details for DOI 10.1177/1945892420912159

    View details for PubMedID 32168996

  • The use of platelet-rich plasma in treatment of olfactory dysfunction: A pilot study LARYNGOSCOPE INVESTIGATIVE OTOLARYNGOLOGY Yan, C. H., Mundy, D. C., Patel, Z. M. 2020

    View details for DOI 10.1002/lio2.357

    View details for Web of Science ID 000514750900001

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

    Abstract

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

    View details for DOI 10.1093/neuros/nyz559

    View details for PubMedID 31950156

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

    Abstract

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

    View details for DOI 10.1002/alr.22460

    View details for PubMedID 31899857

  • Endoscopic Endonasal Approach for Resection of Suprasellar Hemangioblastoma: Selective Pituitary Sacrifice and Use of Indocyanine Dye: 2-Dimensional Operative Video. Operative neurosurgery (Hagerstown, Md.) Abhinav, K. n., Gimenez, P. n., Tyler, M. n., Patel, Z. M., Fernandez-Miranda, J. C. 2020

    Abstract

    Suprasellar hemangioblastomas are rare lesions occurring sporadically or more commonly with von Hippel Lindau disease (VHLD).1,2 A 27-yr-old female presented with amenorrhea, mildly raised prolactin levels and otherwise normal pituitary function, homonymous hemianopia, and mild cognitive decline. Imaging revealed a large suprasellar lesion arising from the infundibulum, causing compression of optic chiasm with edema in the visual pathways. Lesion appeared hypervascular with prominent feeding vessels from the internal carotid arteries bilaterally. To access these vessels derived from the superior hypophyseal arteries and allow early devascularization, endoscopic endonasal approach was performed.3 Stalk preservation was deemed unlikely. After opening of the suprasellar dura, indocyanine dye allowed early identification of the feeding vessels. They were sequentially sacrificed, allowing early devascularization while preserving the normal blood supply to the optic chiasm from the superior hypophyseal arteries. Pituitary gland and stalk were removed with the latter being completely involved by tumor to provide access to the retroclival region and posterior circulation. After opening of the dura underlying the dorsum sella, inferior pole of the tumor was exposed with blood supply identified from the posterior communicating arteries but not the basilar or posterior cerebral arteries. Devascularized lesion was safely removed from the optic apparatus, hypothalamus, and the third ventricle. Histology was consistent with hemangoblastoma (VHLD negative). Patient's cognitive and visual function normalized with a postoperative magnetic resonance imagingdemonstrating complete resection, no ischemic events on diffusion-weighted imaging, and resolution of the edema in the hypothalamus and visual pathways.1 She was started on desmopressin and replacement therapy for pituitary function. The patient consented to the procedure.  Patient provided consent for publication.

    View details for DOI 10.1093/ons/opaa250

    View details for PubMedID 32814970

  • Reflections and new developments within the COVID-19 pandemic. International forum of allergy & rhinology Patel, Z. M. 2020; 10 (5): 587–88

    View details for DOI 10.1002/alr.22582

    View details for PubMedID 32297469

  • Rising to the Challenge: Otolaryngologists in the COVID-19 Pandemic. Otolaryngologic clinics of North America Patel, Z. M. 2020; 53 (6): xxvii-xxviii

    View details for DOI 10.1016/j.otc.2020.09.019

    View details for PubMedID 33127044

  • COVID-19 and the otolaryngologist - preliminary evidence-based review. The Laryngoscope Vukkadala, N. n., Qian, Z. J., Holsinger, F. C., Patel, Z. M., Rosenthal, E. n. 2020

    Abstract

    The SARS-CoV-2 virus which causes coronavirus disease 2019 (COVID-19) has rapidly swept across the world since its identification in December 2019. Otolaryngologists are at unique risk due to the close contact with mucus membranes of the upper respiratory tract and have been among the most affected healthcare workers in Wuhan, China. We present information on COVID-19 management relevant to otolaryngologists on the frontlines of this pandemic and provide preliminary guidance based on practices implemented in China and other countries and practical strategies deployed at Stanford University. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/lary.28672

    View details for PubMedID 32219846

  • Olfactory Loss of Function as a Possible Symptom of COVID-19. JAMA otolaryngology-- head & neck surgery Lechner, M. n., Patel, Z. M., Philpott, C. n., Lund, V. J. 2020

    View details for DOI 10.1001/jamaoto.2020.1589

    View details for PubMedID 32672804

  • International Registry of Otolaryngologist - Head and Neck Surgeons with COVID-19. International forum of allergy & rhinology Sowerby, L. J., Stephenson, K. n., Dickie, A. n., Lella, F. A., Jefferson, N. n., North, H. n., De Siati, R. D., Maunsell, R. n., Herzog, M. n., Nandhan, R. n., Trozzi, M. n., Dehgani-Mobaraki, P. n., Melkane, A. n., Callejas, C. n., Miljeteig, H. n., Smit, D. n., Reynoso, D. D., Moura, J. E., Hermansson, A. n., Peer, S. n., Burnell, L. n., Fakhry, N. n., Chiesa-Estomba, C. n., Önerci Çelebi, Ö. n., Karpischenko, S. n., Sobol, S. n., Sargi, Z. n., Patel, Z. M. 2020

    Abstract

    It has become clear that healthcare workers are at high risk, and otolaryngology has been theorized to be among the highest risk specialties for COVID-19.  The purpose of this study is to detail the international impact of COVID-19 among otolaryngologists, and to identify instructional cases.Country representatives of the Young Otolaryngologists - International Federation of Otolaryngologic Societies (YO-IFOS) surveyed otolaryngologists through various channels. Nationwide surveys were distributed in 19 countries. The grey literature and social media channels were searched to identify reported deaths of otolaryngologists from COVID-19.A total of 361 otolaryngologists were identified to have had COVID-19, and data for 325 surgeons was available for analysis. The age range was 25 to 84, with half under the age of 44.  There were 24 deaths in the study period, with 83% over age 55. Source of infection was likely clinical activity in 175 (54%) cases.  Prolonged exposure to a colleague was the source for 37 (11%) surgeons. Six instructional cases were identified where infections occurred during the performance of aerosol-generating operations (tracheostomy, mastoidectomy, epistaxis control, dacryocystorhinostomy and translabyrinthine resection). In three of these cases, multiple operating room attendees were infected, and in two, the surgeon succumbed to complications of COVID-19.The etiology of reported cases within the otolaryngology community appear to stem equally from clinical activity and community spread. Multiple procedures performed by otolaryngologists are aerosol generating procedures (AGPs) and great care should be taken to protect the surgical team before, during, and after these operations. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/alr.22677

    View details for PubMedID 32735062

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

    Abstract

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

    View details for DOI 10.1177/0194599820917396

    View details for PubMedID 32343633

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

    Abstract

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

    View details for DOI 10.1101/2020.05.08.20092866

    View details for PubMedID 32511516

    View details for PubMedCentralID PMC7273284

  • Update on long-term outcomes for chronic rhinosinusitis in cystic fibrosis. Current opinion in otolaryngology & head and neck surgery Chang, M. T., Patel, Z. M. 2019

    Abstract

    PURPOSE OF REVIEW: This article reviews the existing body of literature regarding long-term outcomes of various treatments for chronic rhinosinusitis (CRS) in the cystic fibrosis population.RECENT FINDINGS: The management of CRS in cystic fibrosis involves a multitude of medical and surgical therapies. Despite their high usage amongst clinicians, corticosteroids and antibiotics currently have little outcome data supporting their use. There is emerging evidence demonstrating beneficial outcomes for DNAse mucolytics and molecular modulators of cystic fibrosis transmembrane conductor regulator (CFTR). Endoscopic sinus surgery (ESS) improves sinonasal outcomes in cystic fibrosis CRS; however, the benefit on pulmonary outcomes remains unclear.SUMMARY: Successful management of CRS in cystic fibrosis requires multimodal and multidisciplinary care. The long-term outcome data is variable for different treatment modalities. There is recent evidence supporting the role of DNAse mucolytics, CFTR-targeting therapies, and ESS in management of cystic fibrosis CRS.

    View details for DOI 10.1097/MOO.0000000000000596

    View details for PubMedID 31815863

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

    Abstract

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

    View details for DOI 10.4193/Rhin19.213

    View details for PubMedID 31671433

  • Follow-up Management of Patients After Transsphenoidal Approach for Resection of Pituitary Adenomas. American journal of rhinology & allergy Ikeda, A. K., Luk, L. J., Patel, Z. M., Oyesiku, N. M., Solares, C. A., DelGaudio, J. M., Levy, J. M., Wise, S. K. 2019: 1945892419879806

    View details for DOI 10.1177/1945892419879806

    View details for PubMedID 31573321

  • Chronic Electrical Stimulation for Tear Secretion: Lacrimal vs. anterior ethmoid nerve. The ocular surface Kossler, A. L., Brinton, M., Patel, Z. M., Dalal, R., Ta, C. N., Palanker, D. 2019

    Abstract

    PURPOSE: To evaluate and compare the effect of lacrimal nerve stimulation (LNS) and anterior ethmoid nerve stimulation (AENS) on aqueous tear secretion, and tissue condition following chronic implantation.METHODS: A neurostimulator was implanted in rabbits adjacent to the (1) lacrimal nerve, and (2) anterior ethmoid nerve. Tear volume was measured with Schirmer test strips after stimulation (2.3-2.8 mA pulses at 30 Hz for 3-5 min), and scores were compared to sham stimulation. Lacrimal gland and nasal septal tissue were evaluated histologically after chronic stimulation (2 weeks-7 months).RESULTS: LNS increases tear volume by 32% above sham (p < 0.05, n = 5), compared with 133% for AENS (p ≤ 0.01, n = 6). AENS also significantly increases tear secretion in the fellow, non-stimulated eye (p ≤ 0.01, n = 6), as expected from the tearing reflex pathway. Histologically, chronic LNS is well tolerated by surrounding tissues while chronic AENS results in nasal mucosal fibrosis and implant extrusion within 3 weeks.CONCLUSIONS: AENS is significantly more effective than LNS at enhancing aqueous tear secretion, including the fellow eye. The lacrimal implant is well tolerated, while the nasal implant requires further design optimization to improve tolerability.

    View details for DOI 10.1016/j.jtos.2019.08.012

    View details for PubMedID 31476515

  • Rates of symptomatology are lower in recurrent sinonasal malignancy than in other recurrent cancers of the head and neck: a multi-institutional study 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. WILEY. 2019: 688–94

    View details for DOI 10.1002/alr.22310

    View details for Web of Science ID 000470911800016

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

    View details for DOI 10.1002/lary.27582

    View details for Web of Science ID 000462650400015

  • The Horizon Sign and Frontal Bar: Two Topographic Landmarks to Confirm Endoscopic Frontal Sinusotomy OTOLARYNGOLOGY-HEAD AND NECK SURGERY Walgama, E. S., Thamboo, A., Tangbumrungtham, N., Ayoub, N., Patel, Z. M., Nayak, J. V. 2019; 160 (4): 740–43
  • 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

    Abstract

    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 PubMedID 30768764

  • Therapeutic use of steroids in non-chronic rhinosinusitis olfactory dysfunction: a systematic evidence-based review with recommendations Yan, C. H., Overdevest, J. B., Patel, Z. M. WILEY. 2019: 165–76

    View details for DOI 10.1002/alr.22240

    View details for Web of Science ID 000457618400006

  • Oncologic management of sinonasal undifferentiated carcinoma CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Tyler, M. A., Holmes, B., Patel, Z. M. 2019; 27 (1): 59–66
  • 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

    Abstract

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

    View details for PubMedID 30691380

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

    Abstract

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

    View details for DOI 10.3171/2019.4.PEDS18693

    View details for PubMedID 31200365

  • Arterial Pseudoaneurysm following Radiotherapy in Patients with a History of Nasopharyngeal Carcinoma. OTO open Choby, G., Tangbumrungtham, N., Dodd, R., Patel, Z. M. 2019; 3 (1): 2473974X18823002

    View details for DOI 10.1177/2473974X18823002

    View details for PubMedID 31236534

  • The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: a double-blind randomized controlled study. International forum of allergy & rhinology Tangbumrungtham, N. n., Hwang, P. H., Maul, X. n., Borchard, N. A., Dholakia, S. S., Patel, Z. M., Nayak, J. V., Choby, G. n. 2019

    Abstract

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

    View details for DOI 10.1002/alr.22468

    View details for PubMedID 31671251

  • High-Efficiency, Selection-free Gene Repair in Airway Stem Cells from Cystic Fibrosis Patients Rescues CFTR Function in Differentiated Epithelia. Cell stem cell Vaidyanathan, S. n., Salahudeen, A. A., Sellers, Z. M., Bravo, D. T., Choi, S. S., Batish, A. n., Le, W. n., Baik, R. n., de la O, S. n., Kaushik, M. P., Galper, N. n., Lee, C. M., Teran, C. A., Yoo, J. H., Bao, G. n., Chang, E. H., Patel, Z. M., Hwang, P. H., Wine, J. J., Milla, C. E., Desai, T. J., Nayak, J. V., Kuo, C. J., Porteus, M. H. 2019

    Abstract

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

    View details for DOI 10.1016/j.stem.2019.11.002

    View details for PubMedID 31839569

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

    Abstract

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

    View details for PubMedID 30515841

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

    View details for DOI 10.1002/alr.22184

    View details for Web of Science ID 000453516400004

  • Transoral 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; 120: 240–43
  • 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

    Abstract

    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 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

    Abstract

    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 PubMedID 30507692

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

    View details for DOI 10.1002/alr.22156

    View details for Web of Science ID 000446274900013

  • 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

    Abstract

    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 PubMedID 30193964

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

    View details for DOI 10.1002/alr.22147

    View details for Web of Science ID 000443132000008

  • Budesonide irrigation with olfactory training improves outcomes compared with olfactory training alone in patients with olfactory loss Nguyen, T. P., Patel, Z. M. WILEY. 2018: 977–81

    View details for DOI 10.1002/alr.22140

    View details for Web of Science ID 000443132000002

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

    Abstract

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

    View details for PubMedID 29999595

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

    View details for DOI 10.1002/alr.22105

    View details for Web of Science ID 000437764300009

  • 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

    Abstract

    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 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

    Abstract

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

    View details for PubMedID 29856526

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

    View details for DOI 10.1002/lary.26907

    View details for Web of Science ID 000434179100010

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

    Abstract

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

    View details for PubMedID 29782068

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

    Abstract

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

    View details for PubMedID 29460675

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

    Abstract

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

    View details for DOI 10.1016/j.wneu.2017.08.058

    View details for PubMedID 28838874

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

    Abstract

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

    View details for PubMedID 28625807

  • Enhanced natural tearing by electrical stimulation of the anterior ethmoid nerve Brinton, M., Kossler, A., Patel, Z., Loudin, J., Franke, M., Ta, C., Palanker, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2017
  • 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

    Abstract

    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 PubMedID 28431436

  • Randomized Controlled Trial Demonstrating Cost-Effective Method of Olfactory Training in Clinical Practice: Essential Oils at Uncontrolled Concentration. Laryngoscope investigative otolaryngology Patel, Z. M., Wise, S. K., DelGaudio, J. M. 2017; 2 (2): 53-56

    Abstract

    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 PubMedID 28894822

    View details for PubMedCentralID PMC5527365

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

    Abstract

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

    View details for DOI 10.1002/alr.21872

    View details for PubMedID 27863163

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

    Abstract

    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 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

    Abstract

    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 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

    Abstract

    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 PubMedID 27579523

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

    Abstract

    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 PubMedID 29070267

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

    Abstract

    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 PubMedID 29204574

  • 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

    Abstract

    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

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

    Abstract

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

    View details for PubMedID 29068050

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

    Abstract

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

    View details for PubMedID 29131540

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

    Abstract

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

    View details for PubMedID 29227048

  • 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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

    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

  • Olfaction following endoscopic skull base surgery. Current opinion in otolaryngology & head and neck surgery Patel, Z. M., DelGaudio, J. M. 2016; 24 (1): 70-4

    Abstract

    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 PubMedID 26679777

  • 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

    Abstract

    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

    Abstract

    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

  • 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

    Abstract

    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

  • 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

    Abstract

    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 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

    Abstract

    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 PubMedID 25833927

  • 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

    Abstract

    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

    Abstract

    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

    View details for PubMedCentralID PMC4496469

  • 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

    Abstract

    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-?

    Abstract

    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

  • Improvement in the Detection of Locoregional Recurrence in Head and Neck Malignancies: F-18 Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography Compared to High-Resolution Contrast-Enhanced Computed Tomography and Endoscopic Examination LARYNGOSCOPE Rangaswamy, B., Fardanesh, M., Genden, E. M., Park, E. E., Fatterpekar, G., Patel, Z., Kim, J., Som, P. M., Kostakoglu, L. 2013; 123 (11): 2664-2669

    Abstract

    To compare the diagnostic efficacy of positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG-PET)/computed tomography (CT) to that of contrast-enhanced high-resolution CT (HRCT) and assess the value of a combinatorial approach in detection of recurrent squamous cell cancer of the head and neck (HNC) and to assess the efficacy of FDG-PET/CT with and without HRCT in comparison to standard-of-care follow-up--physical examination (PE) and endoscopy (E)--in determination of locally recurrent HNC.Retrospective study.A total of 103 patients with HNC underwent FDG-PET/CT and neck HRCT. There were two groups of patients: Group A had an FDG-PET study acquired with low-dose CT, and group B had an FDG-PET study acquired with HRCT. The PET data obtained with or without HRCT were compared on a lesion and patient basis with the results of the PE/E.On a lesion basis, both groups combined had higher sensitivity and negative predictive value (NPV) than the HRCT. Specificity and positive predictive value (PPV) for group B were higher than for group A. On a patient basis, both groups combined had a higher sensitivity and NPV than PE/E, respectively, although specificity of PE/E was higher than that of either group. PET data obtained with either protocol directly influenced treatment.HRCT increases the specificity and PPV of PET/CT when acquired simultaneously with PET. FDG-PET/CT acquired with either LDCT or HRCT has higher accuracy than HRCT alone and increases the sensitivity and NPV of PE/E.

    View details for DOI 10.1002/lary.24077

    View details for Web of Science ID 000326231200027

    View details for PubMedID 23553147

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

    Abstract

    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

    View details for PubMedCentralID PMC3911804

  • 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

    Abstract

    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

    Abstract

    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

    Abstract

    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

    Abstract

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

    View details for DOI 10.1002/alr.21039

    View details for PubMedID 22528624

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

    Abstract

    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

    Abstract

    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

    Abstract

    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

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

    Abstract

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

    View details for Web of Science ID 000239078900006

    View details for PubMedID 16847172