Publications by authors named "Andrew Thamboo"

57 Publications

The effect of prior radiation on the success of ventral skull base reconstruction: A systematic review and meta-analysis.

Head Neck 2021 May 11. Epub 2021 May 11.

Department of Otolaryngology - Head & Neck Surgery, M. D. Anderson Cancer Center, Houston, Texas, USA.

The incidence of cerebrospinal fluid leak after ventral skull base reconstruction is a primary outcome of interest to skull base surgeons. Exposure to pre-operative radiation may put patients at an increased risk of skull base reconstructive failure. A systematic search identified studies which included patients receiving ventral skull base reconstruction in the setting of pre-operative radiation. A meta-analysis using a random effects model was conducted to estimate an odds ratio of cerebrospinal fluid (CSF) leak in patients exposed to pre-operative radiation. A meta-analysis of 13 studies demonstrated that the odds ratio of CSF leak was 1.73 (95% CI 0.98-3.05). The majority of studies (77%) used vascularized tissue grafts for reconstruction. We identified an increased incidence of CSF leak among patients undergoing ventral skull base reconstruction after prior radiation therapy, although not of statistical significance. Skull base surgeons should exercise caution when planning reconstruction in this population.
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http://dx.doi.org/10.1002/hed.26709DOI Listing
May 2021

Virtual Care in Rhinology.

J Otolaryngol Head Neck Surg 2021 Apr 13;50(1):24. Epub 2021 Apr 13.

Department of Otolaryngology - Head and Neck Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada.

Background: The SARS-CoV-2 (COVID) pandemic has resulted in an increase in virtual care. While some specialties are well suited to virtual care, Otolaryngology - Head and Neck Surgery could be limited due to reliance on physical examination and nasal endoscopy, including Rhinology. It is likely virtual care will remain integrated for the foreseeable future and it is important to determine the strengths and weaknesses of this treatment modality for rhinology.

Methods: A survey on virtual care in rhinology was distributed to 61 Canadian rhinologists. The primary objective was to determine how virtual care compared to in-person care in each area of a typical appointment. Other areas focused on platforms used to deliver virtual care and which patients could be appropriately assessed by virtual visits.

Results: 43 participants responded (response rate 70.5%). The majority of participants use the telephone as their primary platform. History taking and reviewing results (lab work, imaging) were reported to be equivalent in virtual care. Non-urgent follow up and new patients were thought to be the most appropriate for virtual care. The inability to perform exams and nasal endoscopy were reported to be significant limitations.

Conclusion: It is important to understand the strengths and limitations of virtual care. These results identify the perceived strengths and weaknesses of virtual care in rhinology, and will help rhinologists understand the role of virtual care in their practices.
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http://dx.doi.org/10.1186/s40463-021-00505-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8042468PMC
April 2021

Canadian Rhinology Working Group consensus statement: biologic therapies for chronic rhinosinusitis.

J Otolaryngol Head Neck Surg 2021 Mar 9;50(1):15. Epub 2021 Mar 9.

Division of Otolaryngology-Head and Neck Surgery, Centre Hospitalier de l'University de Montreal, Montreal, QC, Canada.

Background: Recent evidence suggests that biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of chronic rhinosinusitis with nasal polyposis (CRSwNP). There remains a population in CRSwNP that despite medical therapy and endoscopic sinus surgery have persistent signs and symptoms of disease. Therefore, biologics, monoclonal antibody agents, could be beneficial therapeutic treatments for these patients. There have been eight randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL-5R, IL-33, and immunoglobulin (Ig)E. However, there are no formal recommendations for the optimal use of biologics in managing Chronic Rhinosinusitis (CRS) within the Canadian health care environment.

Methods: A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. 17 fellowship trained rhinologists across Canada evaluated the 28 original statements on a scale of 1-10 and provided comments. A rating within 1-3 indicated disagreement, 8-10 demonstrated agreement and 4-7 represented being neutral towards a statement. All ratings were quantitively reviewed by mean, median, mode, range and standard deviation. Consensus was defined by removing the highest and lowest of the scores and using the "3 point relaxed system".

Results: After three rounds, a total of 11 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with CRS.

Conclusion: This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of patients with CRS, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.
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http://dx.doi.org/10.1186/s40463-021-00493-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945300PMC
March 2021

5-year outcomes of salvage endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma.

J Otolaryngol Head Neck Surg 2021 Feb 17;50(1):12. Epub 2021 Feb 17.

Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.

Objective: Recurrent nasopharyngeal carcinoma (rNPC) can be salvaged with re-irradiation, open nasopharyngectomy, and more recently endoscopic nasopharyngectomy. However, long-term outcomes of endoscopic approaches are lacking. Thus, we report 5-year outcomes following endoscopic nasopharyngectomy for rNPC.

Methods: Patients who underwent endoscopic nasopharyngectomy for rNPC between January 2000 and January 2012 were retrospectively reviewed. Patients were included if they had their first endoscopic nasopharyngectomy at least 5 years prior to this study. Presenting (cTNM) status and recurrent (rTNM) status for each recurrence was determined. Outcomes included margin status, disease recurrence, death, and complication rates.

Results: Thirteen patients were included. Four patients had a prior open nasopharyngectomy. Mean time follow-up was 74.3 months (range = 56.4-96 months). Negative margins were achieved in 77% of initial cases. Positive margins were associated with higher rT stages. Re-recurrence was seen in 6 patients, which was also associated with a higher cStage and rStage. All patients with positive margins had re-recurrence. Four patients required repeat endoscopic nasopharyngectomy and two received chemoradiation. All four with a second endoscopic procedure had further disease recurrence. Five-year local disease-free and overall survival rates were 53.9 and 84.6%, respectively. The minor complication rate was 52.6%, major operative complication rate was 0.0%, and late complication rate was 23.1%.

Conclusion: Endoscopic nasopharyngectomy demonstrates promising 5-year overall survival rate for rT1 and rT2 cases of rNPC with favorable complication rates. Lower rStages were associated with a higher disease-free rate, and lower cStages were associated with improved overall prognosis. Close surveillance and prompt management of recurrences can be associated with favorable long-term tumor control.

Level Of Evidence: 4.
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http://dx.doi.org/10.1186/s40463-020-00482-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888158PMC
February 2021

A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing.

Otolaryngol Head Neck Surg 2021 Feb 16:194599820988740. Epub 2021 Feb 16.

Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Objective: Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed.

Study Design: A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given.

Setting: Patients with nonabsorbable nasal packing placed.

Methods: Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model.

Results: The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective.

Conclusions: Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence.

Level Of Evidence: 3a.
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http://dx.doi.org/10.1177/0194599820988740DOI Listing
February 2021

Treatment and outcomes of nasopharyngeal carcinoma in a unique non-endemic population.

Oral Oncol 2021 03 24;114:105182. Epub 2021 Jan 24.

Division of Otolaryngology - Head and Neck Surgery, University of British Columbia, 4(th) floor, Gordon and Leslie Diamond Health Care Center, 2775 Laurel Street, Vancouver, British Columbia V5Z1M9, Canada.

Objective: Nasopharyngeal carcinoma (NPC) is common in Southeast Asia. Due to the influx of immigrants from this region, the incidence in British Columbia is increasing. Current literature from non-endemic populations encompasses heterogeneous cohorts. This study examines NPC in a North American population, with a high incidence, to understand the population's characteristics, treatment outcomes and recurrence patterns.

Methods And Materials: A retrospective analysis of patients treated for primary and recurrent NPC over 15-years. Regression analyses were used to identify predictors of disease recurrence and death. A subgroup analysis of the locoregional recurrence cohort was conducted. Five-year survival outcomes were determined.

Results: 601 patients were included. Asian ethnicity comprised 77% and the majority had non-keratinizing carcinoma (81%). In total, 19.3% of patients experienced recurrence: 58% local, 22% regional and 20% distant. Five-year overall survival was 70%. Smoking, advancing T-stage, poorer performance status and advanced overall stage were all associated with worse overall survival (p < 0.05). Asian ethnicity improved overall survival but not recurrence free survival. Similar features in addition to non-keratinizing histology were associated with increased locoregional recurrence (p < 0.05). Competing risk analysis indicated radiotherapy alone had a higher recurrence relative to chemoradiotherapy (HR 1.91, CI 1.17-3.09, p = 0.01).

Conclusions: We report the largest study evaluating treatment and outcomes of NPC in a non-endemic population. This unique population falls between described endemic and non-endemic populations. Non-keratinizing pathology and primary radiotherapy did not affect survival; however, both had a propensity for recurrence. Finally, patients experienced more locoregional and less distant recurrence, supporting that this cohort may be amenable to curative salvage therapy.
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http://dx.doi.org/10.1016/j.oraloncology.2021.105182DOI Listing
March 2021

The empty nose syndrome 6-item questionnaire (ENS6Q): a diagnostic tool to distinguish empty nose syndrome from primary nasal obstruction.

Int Forum Allergy Rhinol 2021 Jan 18. Epub 2021 Jan 18.

Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1002/alr.22761DOI Listing
January 2021

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic.

J Otolaryngol Head Neck Surg 2020 Dec 3;49(1):81. Epub 2020 Dec 3.

Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.
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http://dx.doi.org/10.1186/s40463-020-00476-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714255PMC
December 2020

Inferior meatus augmentation procedure (IMAP) normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics (CFD) modeling.

Int Forum Allergy Rhinol 2021 May 29;11(5):902-909. Epub 2020 Nov 29.

Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA.

Background: Empty nose syndrome (ENS) is a controversial upper airway disorder most commonly associated with tissue loss from the inferior turbinates. The inferior meatus augmentation procedure (IMAP) has been shown to effectively reduce ENS symptoms in a durable manner, but the precise mechanisms that may govern this symptomatic improvement remain unknown.

Methods: Five patients with ENS who underwent bilateral IMAP via submucosal costal cartilage implant were assessed. Pre-implant and 6 months post-implant computed tomography (CT) imaging for each ENS patient was analyzed in a blinded fashion using computational fluid dynamics (CFD) modeling to investigate intrapatient changes in airflow parameters.

Results: Following surgery, ENS patients have significantly improved symptoms as indexed by Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) scoring (pre-implant: 14.00 ± 4.06 [mean ± standard deviation]; 95% confidence interval [CI], 10.44 to 17.56; post-implant: 4.8 ± 2.77; 95% CI, 2.37 to 7.23; Cohen's d = 2.64; p = 0.02). Using CFD, a significant shift in nasal airflow patterns was observed, where airflow deviates away from the middle meatus upon hitting the implant (pre-implant: 67.13% ± 11.14%; 95% CI, 60.22% to 74.04%; post-implant: 46.18% ± 12.81%; 95% CI, 38.23% to 54.12%; d = 1.74; p < 0.05) toward the inferior meatus (pre-implant: 30.55% ± 11.29%; 95% CI, 23.55% to 37.55%; post-implant: 42.59% ± 9.60%; 95% CI, 36.63 to 48.54%; d = 1.14; p < 0.05). No significant changes were found in nasal resistance (pre-implant: 0.102 ± 0.015; 95% CI, 0.092 to 0.112 Pa*s/mL; post-implant: 0.105 ± 0.041; 95% CI, 0.081 to 0.130 Pa*s/mL). In addition, the improvement of ENS6Q scoring significantly correlated with percent reduction in aberrant airflow through the middle meatus (R = 0.60, p = 0.04).

Conclusion: This study supports our prior working hypothesis that disordered vectors of nasal airflow congregate in the middle meatus contribute to ENS symptoms, not nasal resistance. Moreover, these data illuminate a paradoxical, but consistent, restoration of nasal airflow to the inferior meatus following the replacement of turbinate tissue volume in the inferior meatus via IMAP surgery, potentially due to the Coandă effect.
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http://dx.doi.org/10.1002/alr.22720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062271PMC
May 2021

The clinical effect of psychosomatic interventions on empty nose syndrome secondary to turbinate-sparing techniques: A prospective self-controlled study.

Int Forum Allergy Rhinol 2021 May 5;11(5):955-956. Epub 2020 Nov 5.

Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1002/alr.22724DOI Listing
May 2021

Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology - head and neck surgery during the COVID-19 pandemic.

J Otolaryngol Head Neck Surg 2020 May 6;49(1):28. Epub 2020 May 6.

Division of Otolaryngology Head & Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.

Background: Aerosol generating medical procedures (AGMPs) present risks to health care workers (HCW) due to airborne transmission of pathogens. During the COVID-19 pandemic, it is essential for HCWs to recognize which procedures are potentially aerosolizing so that appropriate infection prevention precautions can be taken. The aim of this literature review was to identify potential AGMPs in Otolaryngology - Head and Neck Surgery and provide evidence-based recommendations.

Methods: A literature search was performed on Medline, Embase and Cochrane Review databases up to April 3, 2020. All titles and abstracts of retrieved studies were evaluated and all studies mentioning potential AGMPs were included for formal review. Full text of included studies were assessed by two reviewers and the quality of the studies was evaluated. Ten categories of potential AGMPs were developed and recommendations were provided for each category.

Results: Direct evidence indicates that CO2 laser ablation, the use of high-speed rotating devices, electrocautery and endotracheal suctioning are AGMPs. Indirect evidence indicates that tracheostomy should be considered as potential AGMPs. Nasal endoscopy and nasal packing/epistaxis management can result in droplet transmission, but it is unknown if these procedures also carry the risk of airborne transmission.

Conclusions: During the COVID-19 pandemic, special care should be taken when CO2 lasers, electrocautery and high-speed rotating devices are used in potentially infected tissue. Tracheal procedures like tracheostomy and endotracheal suctioning can also result in airborne transmission via small virus containing aerosols.
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http://dx.doi.org/10.1186/s40463-020-00425-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202463PMC
May 2020

Clinical evidence based review and systematic scientific review in the identification of malignant transformation of inverted papilloma.

J Otolaryngol Head Neck Surg 2020 Apr 30;49(1):25. Epub 2020 Apr 30.

St Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada.

Background: Inverted papilloma (IP) is an unusual type of benign tumor that has high recurrence rates and the potential to transform into squamous cell carcinomas (SCC). The mechanism of the transformation process from IP to IP-SCC is uncertain and there is no consensus regarding the best practice for IP-SCC detection. The goal of this study is to identify the best clinical methods to detect for IP-SCC.

Methods: An evidence-based review was performed using Medline and Ovid to obtain all articles up to October 10th, 2019 pertaining to identification of IP malignant transformation. All manuscripts discussing clinical methods or biomarkers were included.

Results: Based on clinical research studies, convoluted cerebriform pattern and apparent diffusion coefficient values on Magnetic Resonance Imaging (MRI) can help differentiate benign IP from SCC and increased SUVmax on PET/CT is associated with higher probability of malignancy although not as specific. No consensus about the best biomarker for IP-SCC has been reached among researchers and continues to be exploratory.

Conclusion: Endoscopy with biopsy is the gold standard practice to identify IP-SCC; however, MRI is the preferred imaging modality to recognize malignant transformation in cases where biopsy is difficult. Multiple biomarkers have shown positive results, but no single indicator with clinical significance for monitoring malignant transformation process has been found.
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http://dx.doi.org/10.1186/s40463-020-00420-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193386PMC
April 2020

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis.

Am J Rhinol Allergy 2020 Jul 24;34(4):519-531. Epub 2020 Mar 24.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.

Background: Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology-head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective: This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods: A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results: Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion: This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.
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http://dx.doi.org/10.1177/1945892420912158DOI Listing
July 2020

The cotton test redistributes nasal airflow in patients with empty nose syndrome.

Int Forum Allergy Rhinol 2020 04 17;10(4):539-545. Epub 2020 Jan 17.

Department of Otolaryngology, Head & Neck Surgery, Stanford University, Stanford, CA.

Background: Empty nose syndrome (ENS) remains a controversial disease primarily associated with inferior turbinate tissue loss. Cotton placement into the inferior meatus often alleviates ENS symptoms within minutes, but the physiologic explanation for this phenomenon is unknown. Computational fluid dynamics (CFD) was employed to evaluate the mechanisms of altered nasal airflow conferred by cotton testing.

Methods: Six ENS patients (12 sides) with pre-existing sinus computed tomography (CT) imaging were enrolled after marked symptomatic improvement (decrease in score on the Empty Nose Syndrome 6-Item Questionnaire [ENS6Q] of >7 points) with office-based cotton testing. The fashioned cotton plug was labeled in situ with iohexol contrast spray, and sinus CT was immediately obtained to detect cotton contouring in the inferior meatus. CT imaging from pre- and post-cotton placement was analyzed using comparative CFD techniques.

Results: After cotton placement, significant symptomatic improvement and reduced ENS6Q scores (16.8 ± 4.1 to 3.1 ± 2.4; p < 0.001) were recorded. Using CFD, cotton placement produced an expected 21% increase in upper airway resistance (p < 0.05). However, a significant shift in the nasal airflow distribution was also detected, with a transition of airflow vectors away from a middle meatus jetstream (-41%; p < 0.002).

Conclusion: Objective CFD assessment confirmed that the cotton test not only increases nasal resistance, but also restores airflow distribution to the inferior meatus in symptomatic ENS patients. These results highlight the potential efficacy of cotton test in ENS patients and further bolster the utility of this tool in identifying appropriate candidates for the inferior meatus augmentation procedure.
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http://dx.doi.org/10.1002/alr.22489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182493PMC
April 2020

Inferior Meatus Augmentation Procedure (IMAP) to Treat Empty Nose Syndrome: A Pilot Study.

Otolaryngol Head Neck Surg 2020 Mar 14;162(3):382-385. Epub 2020 Jan 14.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA.

Our understanding of empty nose syndrome (ENS) continues to evolve. Prior studies evaluating airway augmentation to treat ENS did not use validated disease-specific questionnaires, making the true impact of these surgeries unclear. We present a case series of 10 patients with ENS (11 procedures) who underwent the inferior meatus augmentation procedure (IMAP) between September 2014 and May 2017. Subjective outcomes of IMAP included comparisons of preoperative and postoperative assessments (1 week, 1 month, 3 months, 6 months) using the Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7-item Scale (GAD-7), and Sino-Nasal Outcome Test-22 (SNOT-22). The decrement in ENS6Q scores observed maintained statistical significance at 6 months ( ≤ .001). Similar results were achieved with PHQ-9, GAD-7, and SNOT-22 ( ≤ .01, ≤ .01, ≤ .001, respectively). IMAP can dramatically improve the quality of life of ENS patients regarding both ENS-specific symptoms and psychological well-being.
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http://dx.doi.org/10.1177/0194599819900263DOI Listing
March 2020

The Upper Airway Nasal Complex: Structural Contribution to Persistent Nasal Obstruction.

Otolaryngol Head Neck Surg 2019 07 26;161(1):171-177. Epub 2019 Mar 26.

1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.

Objective: To determine the contribution of the nasal floor and hard palate morphology to nasal obstruction for nonresponders to prior intranasal surgery.

Study Design: Retrospective case-control study.

Setting: Tertiary academic center.

Methods: Institutional review board-approved, retrospective institutional database analysis was obtained of a cohort of 575 patients who presented with nasal obstruction over a 21-year period. Of the patients, 89 met inclusion criteria: 52 were placed into the experimental group, defined as having persistent nasal obstruction following endoscopic sinus surgery (ESS), septoplasty, nasal valve repair, and/or turbinoplasty using validated subjective questionnaires, and 37 were placed into the control group, defined as having resolution of subjective nasal obstruction. Computed tomography imaging was presented to 3 blinded experts, who measured numerous nasal airway and hard palate morphology parameters, including anterior nasal floor width, anterior maxillary angle, maxilla width, anterior nasal floor width, and palatal vault height. Standard demographic information, comorbidities, perioperative 22-item Sinonasal Outcome Test (SNOT-22), and follow-up time were also assessed. Wilcox rank sum analysis or test was performed where appropriate.

Results: Follow-up ranged from 2 to 36 months following surgical intervention. Several skeletal characteristics within the upper airway were significantly associated with persistent nasal obstruction, including acute maxillary angle ( = .035), narrow maxillary width ( = .006), and high arched palate ( = .004).

Conclusion: Persistent nasal obstruction may be seen in patients with narrow, high arched hard palate despite prior nasal surgical intervention and may benefit from additional skeletal remodeling procedures such as maxillary expansion.
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http://dx.doi.org/10.1177/0194599819838262DOI Listing
July 2019

Environmental Triggers Associated With Empty Nose Syndrome Symptoms: A Cross-Sectional Study.

Ann Otol Rhinol Laryngol 2019 Jul 28;128(7):601-607. Epub 2019 Feb 28.

1 St. Paul's Sinus Centre, Vancouver, BC, Canada.

Objectives: Empty nose syndrome (ENS) is thought to have multiple etiologies, one of which is a postsurgical phenomenon resulting from excessive loss of nasal tissues, particularly the inferior turbinate. Given that the inferior turbinate is instrumental in maintaining nasal homeostasis in different environments, it is believed that ENS symptoms arise only in more arid regions of the world. The aim of this study was to recruit an international population of individuals with ENS to investigate the association of local climate factors on the incidence and severity of ENS-specific symptoms.

Methods: A cross-sectional study was performed of individuals from an international ENS database. ENS status was determined on the basis of a positive ENS questionnaire score (Empty Nose Syndrome 6-Item Questionnaire) and sinus computed tomographic imaging with supporting medical documentation. Participants completed a survey encompassing demographic, geographic, and symptom indicators. Climate variables were collected from global climate databases. Participant location was classified according to the Köppen-Geiger climate system. Pearson correlation analysis was performed using α = 0.05 to determine significance.

Results: Fifty-three individuals with ENS were included. Participants were distributed across 5 continents and 15 countries (representing 4 distinct Köppen-Geiger zones). Although local climate factors varied significantly within this cohort, no significant association was found between Empty Nose Syndrome 6-Item Questionnaire symptom severity and these climate factors. However, most study participants reported exacerbation of their ENS symptoms in response to dry air (94%), air conditioning (64%), changes in season and weather (60%), and transitioning between indoors and outdoors (40%). This suggests that everyday local environmental factors may influence the well-being of these patients more than global, climate-level shifts.

Conclusions: ENS symptom severity does not appear to be related to climate or geographic factors. These findings deviate from the traditional dogma that ENS is experienced only in arid regions (or precluded in humid regions) and highlight the importance of recognizing this condition independent of geographic location.
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http://dx.doi.org/10.1177/0003489419833714DOI Listing
July 2019

The association of Leptospermum honey with cytokine expression in the sinonasal epithelium of chronic rhinosinusitis patients.

World J Otorhinolaryngol Head Neck Surg 2019 Mar 7;5(1):19-25. Epub 2018 Sep 7.

St. Paul's Sinus Centre, Division of Otolaryngology, Department of Surgery, St. Paul's Sinus Centre, Vancouver, BC, Canada.

Objective: To identify the differences in cytokine expression between sinonasal tissue from patients treated with Leptospermum (Manuka) honey (LH) irrigation versus normal saline irrigation twice-daily for twelve weeks following sinus surgery (FESS).

Methods: Forty-six CRS patients were recruited. Sinus tissue biopsies were collected during FESS and then at 5 and 12 weeks postoperatively during the course of treatment. A multi-plex cytokine assay quantified the abundance of 17 cytokines in biopsied tissue. Cytokine expression fold-change was analyzed between each time point using a robust linear regression model and compared between the two treatment groups.

Results: Compared to the saline irrigation group, five cytokines were differently expressed ( = 95%) in sinonasal tissue obtained from subjects in the LH irrigation group during the 12-week treatment period. Cytokines IL-6 ( = 0.0400), IL-8 ( = 0.0398), MCP-1 ( = 0.0284), and MIP-1β ( = 0.016) were significantly increased in the LH irrigation group compared to the saline irrigation group. IL-13 was significantly increased in the saline irrigation group compared to the LH group ( = 0.0086).

Conclusion: LH may potentially act to modulate the expression of IL-6, IL-8, IL-13, MCP-1 and MIP-1β in sinonasal tissue.
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http://dx.doi.org/10.1016/j.wjorl.2018.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364513PMC
March 2019

Outcomes of sinonasal inverted papilloma resection by surgical approach: an updated systematic review and meta-analysis.

Int Forum Allergy Rhinol 2019 06 12;9(6):573-581. Epub 2019 Feb 12.

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA.

Background: Selecting the optimal surgical approach for resection of sinonasal inverted papilloma (SIP) remains a challenge, with endoscopic, external, and combined approaches being utilized. This systematic review was conducted as an update to a 2006 systematic review to determine the preferred surgical approach for tumor control.

Methods: The study protocol was developed a priori following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. Data were collected and outcomes were analyzed according to surgical approach and sites of tumor involvement.

Results: A total of 96 papers and 4134 SIP patients were included. The overall recurrence rate was 12.80% (322/2515) for the endoscopic approach group, 16.58% (182/1098) for the external approach group, and 12.60% (65/516) for the combined approach group. Meta-analysis by random effects model showed that the summarized risk ratio (RR) of recurrence was 0.61 (95% confidence interval [CI], 0.44 to 0.85, p = 0.003), I = 37.95% for the endoscopic vs external approach; 0.98 (95% CI, 0.69 to 1.39, p = 0.901), I = 9.06% for the endoscopic vs combined approach; 1.61 (95% CI, 1.06 to 2.43, p = 0.025), I = 0.00% for the external vs combined approach. After adjusting for publication bias, the adjusted RRs were 0.66 (p = 0.014) for endoscopic vs external; 0.99 (p = 0.955) for endoscopic vs combined; and 1.33 (p = 0.224) for external vs combined.

Conclusion: An enlarging and maturing body of literature continues to indicate that endoscopic approaches result in significantly lower recurrence rates than open approaches for surgical resection of SIP.
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http://dx.doi.org/10.1002/alr.22305DOI Listing
June 2019

Use of intranasal submucosal fillers as a transient implant to alter upper airway aerodynamics: implications for the assessment of empty nose syndrome.

Int Forum Allergy Rhinol 2019 06 4;9(6):681-687. Epub 2019 Feb 4.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA.

Background: Empty nose syndrome (ENS) is a debilitating condition associated with inferior turbinate tissue loss. Surgical augmentation of the inferior meatus has been proposed to treat ENS, although efficacy data with validated, disease-specific questionnaires is limited. Instead we evaluated submucosal injection of a transient, resorbable filler into the inferior meatus to favorably alter nasal aerodynamics in ENS patients.

Methods: Patients with a history of inferior turbinate reduction, diagnosed with ENS via Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) and cotton testing, were enrolled and underwent submucosal injection of carboxymethylcellulose/glycerin gel (Prolaryn®) into the inferior meatuses between July 2014 and May 2018. This material likely resorbs over several months. Outcomes included comparisons of preinjection and postinjection symptoms at 1 week, 1 month, and 3 months using the ENS6Q, 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-item scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9).

Results: Fourteen patients underwent injections. Mean ENS6Q scores significantly decreased from baseline at 1 week (20.8 vs 10.5; p < 0.0001), and remained reduced but upward-trending at 1 month (13.7, p = 0.002) and 3 months (15.5, p > 0.05) following injections. Mean SNOT-22 scores significantly decreased at 1 week (p = 0.01) and 1 month (p = 0.04), mean GAD-7 at 1 month (p = 0.02) and 3 months (p = 0.02), and mean PHQ-9 at 1 week (p = 0.01) and 1 month (p = 0.004) postinjection.

Conclusion: Transient, focal airway bulking via submucosal filler injection at sites of inferior turbinate tissue loss markedly benefits ENS patients, suggesting that aberrant nasal aerodynamics from inferior turbinate tissue loss contributes to (potentially reversible) ENS symptoms.
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http://dx.doi.org/10.1002/alr.22299DOI Listing
June 2019

The Horizon Sign and Frontal Bar: Two Topographic Landmarks to Confirm Endoscopic Frontal Sinusotomy.

Otolaryngol Head Neck Surg 2019 04 29;160(4):740-743. Epub 2019 Jan 29.

3 Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Palo Alto, California, USA.

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.
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http://dx.doi.org/10.1177/0194599818825472DOI Listing
April 2019

Precision medicine: why surgeons deviate from "appropriateness criteria" in the management of chronic rhinosinusitis and effects on outcomes.

Int Forum Allergy Rhinol 2018 12 12;8(12):1389-1394. Epub 2018 Jul 12.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA.

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.
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http://dx.doi.org/10.1002/alr.22184DOI Listing
December 2018

Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling.

Int Forum Allergy Rhinol 2018 10 1;8(10):1162-1168. Epub 2018 Jun 1.

Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL.

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.
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http://dx.doi.org/10.1002/alr.22156DOI Listing
October 2018

Potential risk factors associated with the development of synechiae following functional endoscopic sinus surgery.

Eur Arch Otorhinolaryngol 2018 May 15;275(5):1175-1181. Epub 2018 Mar 15.

Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada.

Purpose: Synechiae formation in the middle meatus is the most common complication of functional endoscopic sinus surgery (FESS). Our objectives were to determine the incidence of synechiae occurring in a cohort of patients that have undergone FESS and identify characteristics associated with the development of synechiae postoperatively.

Methods: A retrospective chart review was conducted of CRS patients, with or without nasal polyposis, that had undergone bilateral FESS in the past. All patients had received non-absorbable spacers intraoperatively that were left in situ for 6 days. Demographic and preoperative variables were analyzed to identify synechiae risk factors. A multivariable logistic regression model was constructed to estimate the probability of developing synechiae, given demographic and preoperative variables.

Results: Two hundred cases of bilateral FESS were retrospectively reviewed. Thirty-eight (19.0%, 95% CI 13.6-24.4%) patients developed synechiae. Individuals receiving primary FESS and nasal septal reconstruction (NSR) were strongly associated with the development of synechiae (OR 3.5, 95% CI 1.5-8.5; OR 3.0, 95% CI 1.3-6.9). A multivariable logistic regression model adjusting for NSR, recurrent FESS, concha bullosa, requirement of anterior and posterior ethmoidectomy, Lund-Mackay CT score and gender, identified the likelihood of developing synechiae with a sensitivity of 68%, specificity of 73%, positive predictive value of 38% and likelihood ratio of 2.5.

Conclusion: Patients undergoing primary FESS and NSR are at greatest odds of developing postoperative synechiae. Methods of assessing risk factors and preventing synechiae formation in this population should be evaluated in future prospective investigations.
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http://dx.doi.org/10.1007/s00405-018-4936-1DOI Listing
May 2018

Computed tomography analysis of frontal cell prevalence according to the International Frontal Sinus Anatomy Classification.

Int Forum Allergy Rhinol 2018 07 19;8(7):825-830. Epub 2018 Feb 19.

Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA.

Background: The International Frontal Sinus Anatomy Classification (IFAC) is an international consensus document published in 2016 to standardize the nomenclature of cells in the region of the frontal recess and frontal sinus. The IFAC was designed to be surgically relevant and anatomically precise. The current study was undertaken to assess the prevalence of the frontal cell variants as defined by the IFAC, as well as to determine the interrater reliability of the IFAC.

Methods: Three independent reviewers examined triplanar nondiseased maxillofacial computed tomography (CT) scans to assess the anatomy of the frontal recess according to the IFAC system. The prevalence of each cell type was assessed and interrater reliability was measured using an intraclass correlation coefficient (ICC).

Results: One hundred CT scans (200 sides) were examined. Of the 200 sides, 96.5% contained an agger nasi cell (ICC, 0.82; 95% confidence interval [CI], 0.77-0.86), 30.0% contained a supra agger cell (ICC, 0.89; 95% CI, 0.86-0.92), 20.0% contained a supra agger frontal cell (ICC 0.80; 95% CI 0.74-0.84), 72.0% contained a supra bulla cell (ICC, 0.81; 95% CI, 0.76-0.85), 5.5% contained a supra bulla frontal cell (ICC, 0.71; 95% CI, 0.63-0.77), 28.5% contained a supraorbital ethmoid cell (ICC, 0.78; 95% CI, 0.72-0.83), and 30.0% contained a frontal septal cell (ICC, 0.80; 95% CI, 0.74-0.84). The ICC was good to excellent for identification of all frontal cell types.

Conclusions: This study describes the normative distribution of frontal recess cells in a nondiseased population according to IFAC and demonstrates favorable interrater reliability of the classification system.
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http://dx.doi.org/10.1002/alr.22105DOI Listing
July 2018

The functional and psychological burden of empty nose syndrome.

Int Forum Allergy Rhinol 2018 06 14;8(6):707-712. Epub 2018 Feb 14.

St Paul's Sinus Centre, Vancouver, BC, Canada.

Background: Empty nose syndrome (ENS) is a debilitating disorder thought to arise as a postsurgical phenomenon from excessive loss of nasal tissues. Affected patients often report a profound impact on all aspects of life, but the extent of this burden has not been quantified. We sought to determine the association of ENS with mental health and functional impairments.

Methods: A cross-sectional study was performed of individuals with ENS recruited from online ENS forums. ENS status was validated based on a positive 6-item Empty Nose Syndrome Questionnaire (ENS6Q) score and sinus computed tomography imaging or supporting medical documentation. Subjects completed the ENS6Q, the 9-item Patient Health Questionnaire (PHQ-9) for depression, the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), the Epworth Sleepiness Scale for daytime somnolence (ESS), the Work Productivity and Impairment questionnaire (WPAI), and the 5-dimension EuroQol General Health State Survey (EQ-5D-5L). Pearson correlation analysis was performed with α = 0.05 to determine significance.

Results: Fifty-three ENS individuals were included in the study. Overall, participants reported symptoms consistent with moderate anxiety (μ = 12.7; standard deviation [SD], 5.9) and moderately severe depression warranting treatment (μ = 17.9; SD, 6.8). Participants also noted a 62% reduction in productivity at work (n = 24) and 65% in all other activities (n = 53). ENS6Q symptom severity was correlated with more severe depression (p < 0.001), anxiety (p < 0.001), overall pain/discomfort (p = 0.002), and impairment in activities of daily living (p = 0.003).

Conclusion: ENS individuals carry a clinically significant psychological burden and experience marked difficulties with many activities of daily living. A multimodal approach to address the tissue loss with surgery and cognitive-behavioral therapy for the psychological burden may provide the most optimal outcome.
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http://dx.doi.org/10.1002/alr.22097DOI Listing
June 2018

The prevalence of Eustachian tube dysfunction symptoms in patients with chronic rhinosinusitis.

Int Forum Allergy Rhinol 2018 05 11;8(5):620-623. Epub 2017 Dec 11.

Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA.

Background: 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.

Methods: 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.

Results: 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).

Conclusion: 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.
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http://dx.doi.org/10.1002/alr.22056DOI Listing
May 2018

Evidence for a 'preinvasive' variant of fungal sinusitis: Tissue invasion without angioinvasion.

World J Otorhinolaryngol Head Neck Surg 2017 Mar 25;3(1):37-43. Epub 2017 Mar 25.

Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, USA.

Clinical experience has suggested the existence of an intermediate form of fungal sinusitis between the categories of non-invasive fungal sinusitis (non-IFS) and invasive fungal sinusitis (IFS). This fungal sinusitis variant demonstrates unhealthy mucosa by endoscopy with fungal invasion, but lacks angioinvasion microscopically, representing what clinically behaves as a 'pre-invasive' subtype of fungal sinusitis. Unlike non-IFS disease, patients with pre-invasive fungal sinusitis were still felt to require anti-fungal medications due to histologic presence of invasive fungus. While sharing some clinical features of IFS, these 'intermediate' patients were successfully spared extended and repeated surgical debridements given the microscopic findings, and have been successfully treated with shorter courses of antifungal therapy. These select patients have had favorable outcomes when managed in a judicious and semi-aggressive manner, in an undefined zone between the treatments for routine fungal ball and aggressive IFS.
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http://dx.doi.org/10.1016/j.wjorl.2017.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683596PMC
March 2017

Variables associated with olfactory disorders in adults: A U.S. population-based analysis.

World J Otorhinolaryngol Head Neck Surg 2017 Mar 6;3(1):9-16. Epub 2017 Mar 6.

Department of Otolaryngology, Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Palo Alto, CA 94305, USA.

Objective: 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.

Methods: 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.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1016/j.wjorl.2017.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683598PMC
March 2017

Objective and subjective scar aesthetics with topical Manuka honey post-thyroidectomy: A randomized control study.

World J Otorhinolaryngol Head Neck Surg 2016 Dec 16;2(4):203-207. Epub 2016 Dec 16.

Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305, USA.

Objective: Honey (Manuka honey) has proven to be effective in improving acute and chronic wound healing presumably due to its antibacterial and anti-inflammatory properties. The aim is to determine if Manuka honey decreases scar formation and results in a cosmetically appealing scar.

Methods: A prospective single-blinded randomized control trial was performed. All patients received an 8 cm incision. Patients randomized to honey treatment were instructed to apply Manuka honey paste topically to the incision site once per day post surgery for 4 weeks. The patients' scar was then analyzed objectively by a blinded observer and subjectively at 4 and 8 weeks postoperatively. The primary outcome measure used was the Patient and Observer Scar Assessment Scale (POSAS).

Results: A total of 21 patients completed the entire scar analysis (honey treatment = 9, standard treatment = 12). There was no statistically significant difference between patient scar assessment scale and observer scar assessment scale at 4 and 8 weeks postoperatively.

Conclusion: Despite Honey's reported anti-inflammatory and antibacterial properties, this study did not show a difference in scar appearance when applied.
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http://dx.doi.org/10.1016/j.wjorl.2016.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698533PMC
December 2016