Publications by authors named "Chandala Chitguppi"

24 Publications

  • Page 1 of 1

Surgery with Post-Operative Endoscopy Improves Recurrence Detection in Sinonasal Malignancies.

Ann Otol Rhinol Laryngol 2021 May 6:34894211011449. Epub 2021 May 6.

Department of Otolaryngology and Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Objective: The mainstay of treatment in sinonasal malignancy (SNM) is surgery, and when combined with chemoradiation therapy, often leads to the best overall prognosis. Nasal endoscopy is essential for post-treatment surveillance along with physical exam and radiologic evaluation. The ability to directly visualize the sinus cavities after surgery may also improve early detection of tumor recurrence and is another reason to potentially advocate for surgery in these patients.

Methods: A retrospective chart review of medical records of patients with pathologically proven SNM was conducted from 2005 to 2019.

Results: The nasal cavity and maxillary sinus were the most common primary tumor sub-sites. The most common pathology was squamous cell carcinoma (42%). The median time to recurrence was 9.8 months. Recurrence was initially detected endoscopically in 34.3% patients, by imaging in 62.7% patients, and by physical exam in 3.0% patients. 67 (29%) total recurrences were detected on follow-up, of which 46 (68.7%) were local. Twenty-three of the local recurrences were identified via nasal endoscopy. Thirteen recurrences were identified via endoscopic surveillance within the surgically patent paranasal sinuses while 13 were identified within the nasal cavity; 5 patients had multiple sites of recurrence.

Conclusion: Local recurrence of SNM is the most common site for recurrent disease and nasal endoscopy identified half of these cases. 50% of these recurrences were within the paranasal sinuses and would not have been easily identified if the sinuses were not open for inspection. Thus, open sinus cavities aid in the detection of tumor recurrence and is another advantage of surgery in the management of SNM.
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http://dx.doi.org/10.1177/00034894211011449DOI Listing
May 2021

Assessment of narcotic use in management of post-op pain after functional endoscopic sinus surgery.

Laryngoscope Investig Otolaryngol 2021 Feb 9;6(1):42-48. Epub 2021 Jan 9.

Department of Otolaryngology-Head & Neck Surgery Thomas Jefferson University Hospital Philadelphia Pennsylvania USA.

Objectives: Pain and analgesic requirements after functional endoscopic sinus surgery (FESS) vary widely. This study aims to quantify pain after routine FESS and determine the most commonly used pain management regimen.

Methods: Retrospective chart review of 100 patients who underwent FESS from Oct 2017 to May 2019. Patients prospectively completed a daily pain diary and reported pain levels that were categorized into no pain (0), mild (1-3), moderate (4-7), or severe (8-10). Patients were categorized into narcotics, non-narcotics, combination, or none based on type of analgesic used.

Results: Sixty-nine patients were included. Majority of patients reported either mild (39%) or no pain (28%) during the first 5 PODs. Mean POD1 pain score was 3.98, which decreased with each subsequent POD. On POD1, 37% used opioids (n = 37), 32% used non-opioids (n = 32), 22% used a combination (n = 22), and 9% used no pain meds (n = 9). Mean number of narcotic pills used within the first 5 PODs was 2 pills on any given day. Age was inversely associated with reported POD1 pain scores ( = .003) and use of preoperative steroids in patients with sinonasal polyposis was associated with lower POD1 pain scores ( = .03).

Conclusions: Even on POD1, majority of patients experienced either mild or no pain, and this decreases with each POD. Narcotics are grossly overprescribed and underutilized by patients postoperatively after FESS. We advocate for more judicious prescribing habits of narcotics by Otolaryngologists after FESS, and emphasize relying on non-narcotic alternatives like Acetaminophen or NSAIDS to diminish narcotic use and abuse in the postoperative period.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883617PMC
February 2021

Loss of Expression Confers Poor Prognosis to Sinonasal Undifferentiated Carcinoma.

J Neurol Surg B Skull Base 2020 Dec 24;81(6):610-619. Epub 2019 Jul 24.

Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, United States.

 Due to the diverse histopathologic features and variable survival rates seen in sinonasal undifferentiated carcinoma (SNUC), it is likely that this diagnostic entity is comprised of a heterogonous group of morphologically undifferentiated tumors. As advancements in molecular testing have led to a better understanding of tumor biology, it has become increasingly evident that SNUC may actually encompass several tumor subtypes with different clinical behavior. As a result, it is also likely that all SNUC patients cannot be treated in the same fashion. Recent investigations have identified loss of the tumor suppressor (INI1) expression in a subset of undifferentiated sinonasal tumors and extrasinonasal tumors and, studies have suggested that this genetic aberration may be a poor prognostic marker. The objective of this study was to identify differential expression of in SNUC and to analyze and compare the survival outcomes in SNUC patients with and without expression.  All cases of undifferentiated or poorly differentiated neoplasms of the sinonasal tract treated between 2007 and 2018 at a single tertiary care institution were selected. All cases of SNUC were tested for status by immunohistochemistry (IHC). Clinical parameters were analyzed using Student's -test and Fischer's test. Kaplan-Meier methods were used to estimate survival durations, while comparison between both the subgroups was done using the log-rank test. Statistical analysis was performed with the use of SPSS software, Version 25 (IBM, New York, NY, United States).  Fourteen cases of SNUC were identified. Approximately two-thirds (64%;  = 9) of patients were male and the majority (79%;  = 11) were between fifth to seventh decade. Skull base and orbital invasion were seen in 79% (  = 11) and 93% (  = 13) of cases, respectively. Fifty-seven percent of tumors (  = 8) retained expression by IHC (SR-SNUC), while the remaining 43% (  = 6) showed loss of expression and, thus, were considered as -deficient (SD-SNUC). Although clinicopathological features and treatment modalities were similar, SD-SNUC showed poorer (OS:  = 0.07; disease free survival [DFS]:  = 0.02) overall survival (OS) and DFS on Kaplan-Meier curves. Additionally, SD-SNUC showed higher recurrence (75 vs. 17%) and mortality (67 vs. 14%) (hazard rate = 8.562;  = 0.05) rates. Both OS (28.82 ± 31.15 vs. 53.24 ± 37.50) and DFS durations (10.62 ± 10.26 vs. 43.79 ± 40.97) were consistently worse for SD-SNUC. Five-year survival probabilities were lower for SD-SNUC (0.33 vs. 0.85).  SNUC represents a heterogeneous group of undifferentiated sinonasal malignancies. Based on the status of expression, the two subgroups SD-SNUC and SR-SNUC appear to represent distinct clinical entities, with loss of expression conferring an overall worse prognosis.
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http://dx.doi.org/10.1055/s-0039-1693659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755502PMC
December 2020

Quality of Life Outcomes in Patients With Sinonasal Malignancy After Definitive Treatment.

Laryngoscope 2021 07 25;131(7):E2212-E2221. Epub 2020 Dec 25.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: To describe multidimensional quality of life (QOL) outcomes in patients with sinonasal malignancies (SNM). To elucidate factors predicting worse QOL in this population.

Study Design: Retrospective chart review at tertiary institution.

Methods: A retrospective chart review on patients treated for SNM from 2006 to 2019 at a tertiary medical center was conducted. QOL outcomes were measured using the Hospital Anxiety and Depression Scale (HADS) and the Functional Assessment Cancer Therapy - Nasopharynx (FACT-NP) score. A stepwise multiple linear regression analysis was conducted to assess factors predicting worse QOL.

Results: Eighty-one patients met inclusion criteria. Twelve (14.8%) patients had a subscale score >11 for anxiety (HADS-A) or depression (HADS-D) indicating significant anxiety or depression, at a median of 24 (8-68.5) months post treatment. The median FACT-NP total score was 136 (110-152). On multivariable analysis, advanced T classification, single status, and worse social support survey score were significant predictors of worse HADS score. Worse social support survey score was a significant predictor of worse total FACT-NP score.

Conclusion: After adjusting for confounders, at a median of 24 months after completion of definitive therapy for SNM, advanced T classification and single relationship status were found to be significant predictors of anxiety and depression (based on HADS). A worse social support survey score was associated with worse anxiety, depression, and QOL (based on HADS and FACT-NP). Identifying these factors early may help to guide treatment and psychiatric referral to at-risk individuals after the treatment of SNM.

Level Of Evidence: 3 Laryngoscope, 131:E2212-E2221, 2021.
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http://dx.doi.org/10.1002/lary.29339DOI Listing
July 2021

Effect of Benralizumab in Patients With Severe Eosinophilic Asthma and Chronic Rhinosinusitis With Nasal Polyps: A Case Series.

Am J Rhinol Allergy 2020 Dec 10:1945892420978351. Epub 2020 Dec 10.

Department of Pulmonology and Respiratory Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Objective: To analyze the effect of benralizumab in severe eosinophilic asthma (SA) and chronic rhinosinusitis with polyps (CRSwP).

Methods: Retrospective review of patients with SA and CRSwP that were treated with benralizumab. Asthma controlled test (ACT), pulmonary function metrics (FEV1), Meltzer endoscopic polyp scores, SNOT-22 scores, were collected before and after at least 4 months of benralizumab therapy.

Results: 23 patients were included. The mean age at the time of enrollment into benralizumab therapy was 50.47 ± 17.3 years and majority (65.2%, n = 15) were males.Pulmonary Effects: In comparison to baseline ACT, scores at four months showed significant improvement (p = 0.03). In those with pre and post spirometry measurements, mean FEV1 showed significant increase following benralizumab therapy (p = 0.04) with a mean increase of 547 mL ± 597 mL following therapy.Sinonasal Effects: 78.5% of subjects on benralizumab had a significant improvement in sinonasal symptoms (p = 0.009) based on their SNOT-22 scores. Additionally, there was an improvement in endoscopic polyp scores, although not statistically significant, following benralizumab therapy (p = 0.2) with 54.5% patients showing improvement.

Conclusion: Usage of benralizumab in patients with SA and CRSwNP can lead to significantly improved asthma control, lung function, and sinonasal quality of life. Additionally, in this patient population, there was a subset of patients that showed a significant reduction in polyp burden.
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http://dx.doi.org/10.1177/1945892420978351DOI Listing
December 2020

Preoperative Screening for Obstructive Sleep Apnea Prior to Endoscopic Skull Base Surgery: A Survey of the North American Skull Base Society.

Allergy Rhinol (Providence) 2020 Jan-Dec;11:2152656720968801. Epub 2020 Nov 12.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: Obstructive sleep apnea (OSA) is a commonly seen comorbidity in patients undergoing endoscopic skull base surgery and its presence may influence perioperative decision-making. Current practice patterns for preoperative screening of OSA are poorly understood.

Objective: The objective of this study was to assess how endoscopic skull base surgeons screen for OSA, and how knowledge of OSA affects perioperative decision-making.

Methods: Seven question survey distributed to members of the North American Skull Base Society.

Results: Eighty-eight responses (10% response rate) were received. 60% of respondents were from academic centers who personally performed >50 cases per year. Most respondents noted that preoperative knowledge of OSA and its severity affected postoperative care and increased their concern for complications. Half of respondents noted that preoperative knowledge of OSA and its severity affects intraoperative skull base reconstruction decision-making. 70% of respondents did not have a preoperative OSA screening protocol. Body mass index and patient history were most frequently used by those who screened. Validated screening questionnaires were rarely used. 76% of respondents agreed or somewhat agreed that a preoperative polysomnogram should ideally be performed for patients with suspected OSA; however, 50% of respondents reported that <20% of their patients with suspected OSA are advised to obtain a preoperative polysomnogram.

Conclusion: This study reveals that most endoscopic skull base surgeons agree that OSA affects postoperative patient care, but only a minority have a preoperative screening protocol in place. Additional study is needed to assess the most appropriate screening methods and protocols for OSA patients undergoing endoscopic skull base surgery.
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http://dx.doi.org/10.1177/2152656720968801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672726PMC
November 2020

Tolerance of Continuous Positive Airway Pressure After Sinonasal Surgery.

Laryngoscope 2021 03 16;131(3):E1013-E1018. Epub 2020 Sep 16.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: For patients with obstructive sleep apnea (OSA) undergoing sinonasal surgery, there is a lack of consensus on the risk and appropriate postoperative use of continuous positive airway pressure (CPAP). The aim of this study was to assess the tolerability of restarting CPAP on postoperative day one.

Study Design: Prospective cohort study.

Methods: A prospective study on patients with OSA on CPAP who required a septoplasty/turbinectomy and/or functional endoscopic sinus surgery (FESS) was performed. Data from the memory card of a patient's CPAP machine and subjective information were obtained on the day of surgery and at scheduled follow-up visits. All subjects were instructed to restart CPAP on the first postoperative night.

Results: A total of 14 patients were analyzed; nine underwent FESS and five had a septoplasty/turbinectomy. There were no postoperative complications encountered. The only significant change in the first postoperative week was a reduction in the percentage of nights used over 4 hours (P < .05). By the third postoperative visit, average 22-item Sino-Nasal Outcome Test, Nasal Obstruction Symptom Evaluation, and CPAP tolerance scores improved from preoperative values. CPAP pressures, residual apnea-hypopnea index, and number of hours and mean percentage of nights used remained stable throughout the study period.

Conclusions: Both quality-of-life and CPAP outcomes improved or remained the same when restarting CPAP immediately postoperatively. Combined with a lack of significant complications, this study suggests that CPAP is well-tolerated when restarted the day after a septoplasty/turbinectomy or FESS.

Level Of Evidence: 4 Laryngoscope, 131:E1013-E1018, 2021.
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http://dx.doi.org/10.1002/lary.28968DOI Listing
March 2021

Quantitative determination of the optimal temporoparietal fascia flap necessary to repair skull-base defects.

Int Forum Allergy Rhinol 2020 11 7;10(11):1249-1254. Epub 2020 Jul 7.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: The ability to reconstruct large cranial base defects has greatly improved with the development of pedicled vascularized flaps. The temporoparietal fascia flap (TPFF) is a viable alternative to the Hadad-Bassagasteguy nasoseptal flap for large ventral skull-base defects. This study aims to characterize the size of the TPFF necessary for optimal ventral skull-base reconstruction.

Methods: Eleven formaldehyde-fixed cadaveric heads were used to harvest TPFF of varying heights on each side (total = 22). TPFF was passed through the pterygomaxillary fissure (PMF) to the ventral skull base to assess its coverage. For a subgroup of 12 sides, the TPFF was trimmed to determine the minimum height necessary for coverage.

Results: The TPFF height was (mean ± standard deviation [SD]) 14.72 ± 1.02 cm (range, 12.5 to 16.5 cm) and width was 8.43 ± 1.05 cm (range, 6 to 10.5 cm). The distance from the TPFF pedicle through the PMF was 5.8 ± 0.5 cm (range, 5 to 6.5 cm). All TPFF flaps provided complete ipsilateral coverage of clival defects, and all but 1 covered the entire clivus. All TPFF flaps, when rotated anteriorly, provided coverage up to the cribriform plate. The minimum TPFF height necessary for complete coverage of cribriform defects and ventral defects up to the planum sphenoidale was 12 cm. TPFF height for specimens with and without complete ventral skull-base coverage was significantly different (p < 0.0001).

Conclusion: The TPFF is a versatile alternative to the nasoseptal flap and a height of at least 12 cm can provide enough coverage for all ventral skull base defects.
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http://dx.doi.org/10.1002/alr.22609DOI Listing
November 2020

Aerosolized Particle Reduction: A Novel Cadaveric Model and a Negative Airway Pressure Respirator (NAPR) System to Protect Health Care Workers From COVID-19.

Otolaryngol Head Neck Surg 2020 07 19;163(1):151-155. Epub 2020 May 19.

Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Objectives: This study aimed to identify escape of small-particle aerosols from a variety of masks using simulated breathing conditions. This study also aimed to evaluate the efficacy of a negative-pressure environment around the face in preventing the escape of small aerosolized particles.

Study Design: This study is an evaluation study with specific methodology described below.

Setting: This study was performed in our institution's fresh tissue laboratory.

Subjects And Methods: A fixed cadaver head was placed in a controlled environment with a black background, and small-particle aerosols were created using joss incense sticks (mass-median aerosol diameter of 0.28 µ). Smoke was passed through the cadaver head, and images were taken with a high-resolution camera in a standardized manner. Digital image processing was used to calculate relative amounts of small-particle escape from a variety of masks, including a standard surgical mask, a modified Ambu mask, and our negative airway pressure respirator (NAPR).

Results: Significant amounts of aerosolized particles escaped during the trials with no mask, a standard surgical mask, and the NAPR without suction. When suction was applied to the NAPR, creating a negative-pressure system, no particle escape was noted.

Conclusion: We present a new and effective method for the study of small-particle aerosols as a step toward better understanding the spread of these particles and the transmission of coronavirus disease 2019. We also present the concept of an NAPR to better protect health care workers from aerosols generated from the upper and lower airways.
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http://dx.doi.org/10.1177/0194599820929275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240316PMC
July 2020

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma.

Int Forum Allergy Rhinol 2020 06 3;10(6):785-790. Epub 2020 May 3.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas.

Methods: A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586).

Results: The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis.

Conclusion: For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).
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http://dx.doi.org/10.1002/alr.22540DOI Listing
June 2020

Qualitative Assessment of the Effect of Continuous Positive Airway Pressure on the Nasal Cavity.

Am J Rhinol Allergy 2020 Jul 26;34(4):487-493. Epub 2020 Feb 26.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: For patients with obstructive sleep apnea (OSA), there is a lack of knowledge regarding the impact of continuous positive airway pressure (CPAP) on the nasal cavity. There is a significant need for evidence-based recommendations regarding the appropriate use of CPAP following endoscopic sinus and skull base surgery.

Objective: The goal of this study is to translate a previously developed cadaveric model for evaluating CPAP pressures in the sinonasal cavity by showing safety in vivo and quantifying the effect of positive pressurized air flow on the nasal cavity of healthy individuals where physiologic effects are at play.

Methods: A previously validated cadaveric model using intracranial sensor catheters has proved to be a reliable technique for measuring sinonasal pressures. These sensors were placed in the nasal cavity of 18 healthy individuals. Pressure within the nose was recorded at increasing levels of CPAP.

Results: Overall, nasal cavity pressure was on average 85% of delivered CPAP. The amount of pressure delivered to the nasal cavity increased as the CPAP increased. The percentage of CPAP delivered was 77% for 5 cmHO and increased to 89% at 20 cmHO. There was a significant difference in mean intranasal pressures between all the levels of CPAP except 5 cmHO and 8 cmHO ( < .001).

Conclusion: On average, only 85% of the pressure delivered by CPAP is transmitted to the nasal cavity. Higher CPAP pressures delivered a greater percentage of pressurized air to the nasal cavity floor. Our results are comparable to the cadaver model, which demonstrated similar pressure delivery even in the absence of anatomic factors such as lung compliance, nasal secretions, and edema. This study demonstrates the safety of using sensors in the human nasal cavity. This technology can also be utilized to evaluate the resiliency of various repair techniques for endoscopic skull base surgery with CPAP administration.
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http://dx.doi.org/10.1177/1945892420908749DOI Listing
July 2020

Treatment-related morbidity in patients treated for sinonasal malignancy.

Int Forum Allergy Rhinol 2020 04 12;10(4):526-532. Epub 2020 Jan 12.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA.

Background: Sinonasal malignancies are a rare, heterogeneous group of tumors that often present at an advanced stage and require multimodal therapy. The presence of high-grade toxicity and sinonasal complications after treatment can negatively impact quality of life. In this study we aim to describe posttreatment morbidity in patients with sinonasal malignancy.

Methods: A retrospective analysis of all patients treated for sinonasal malignancy was conducted from 2005 to 2018 at a tertiary referral institution. A total of 129 patients met the inclusion criteria. Primary outcomes were treatment details, pathology, posttreatment complications, and radiation toxicity. Fisher's exact test, chi-square test, and Student t test were used for statistical analysis.

Results: Mean age was 58.4 (median, 61; range, 19-94) years. After diagnosis, 24 patients had surgery alone, 46 had surgery with radiation alone, 47 had surgery with chemoradiation, and 14 received definitive chemoradiation. Overall, 10.4% (n = 12) of patients had postoperative complications, and 21.0% (n = 22) had high-grade (grade 3-5) radiation toxicity. After radiation, 20% (n = 21) of patients had chronic sinusitis requiring functional endoscopic sinus surgery and 20% (n = 21) had symptomatic nasal obstruction requiring operative debridement.

Conclusion: Sinonasal complications, including nasal obstruction and chronic sinusitis, occur frequently after definitive treatment of sinonasal malignancy and should be addressed when considering quality of life in survivors. These complications occur more frequently in patients who undergo chemoradiation as opposed to surgery alone.
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http://dx.doi.org/10.1002/alr.22509DOI Listing
April 2020

Rate of rhinosinusitis and sinus surgery following a minimally destructive approach to endoscopic transsphenoidal hypophysectomy.

Int Forum Allergy Rhinol 2020 03 25;10(3):405-411. Epub 2019 Nov 25.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: There remains considerable variation in the extent of sinonasal preservation during the approach for endoscopic transsphenoidal hypophysectomy (TSH). We advocate for a minimally destructive approach utilizing turbinate lateralization, small posterior septectomy, no ethmoidectomy, and preservation of nasoseptal flap (NSF) pedicles bilaterally. Due to these factors, this approach may affect the rates of postoperative rhinosinusitis. The objective of this study is to define the rates of postoperative rhinosinusitis in patients undergoing this approach.

Methods: Single institution, retrospective chart review of patients undergoing TSH from 2005 to 2018.

Results: A total of 415 patients were identified and 14% developed an episode of postoperative rhinosinusitis within 3 months. These patients were significantly more likely to have had a history of recurrent acute or chronic rhinosinusitis. Most cases were sphenoethmoidal sinusitis managed with 1 to 2 courses of antibiotics. Of patients with postoperative rhinosinusitis, most did not undergo NSF. Average follow-up was 38 months. Six patients (1.4%) underwent post-TSH functional endoscopic sinus surgery (FESS). Average time from TSH to FESS was 26.3 months. Two of these patients had a history of prior chronic rhinosinusitis without polyposis. Two patients underwent revision TSH for recurrent tumor as the primary indication for surgery at time of FESS. Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores generally increased immediately postoperatively, but frequently decreased below preoperative level by the time of last follow-up, regardless of whether patients developed rhinosinusitis.

Conclusion: Sinonasal preservation during TSH is associated with a low rate of postoperative rhinosinusitis requiring FESS and excellent long-term patient reported outcomes. We continue to advocate for sinonasal preservation during pituitary surgery.
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http://dx.doi.org/10.1002/alr.22482DOI Listing
March 2020

Microscopic tumor invasion of contralateral mucosa in cancer involving unilateral septum.

Head Neck 2019 10 1;41(10):3535-3541. Epub 2019 Aug 1.

Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: Preservation of contralateral mucosa with microscopic tumor invasion in unilateral septal involvement increases the recurrence risk. The purpose of this study was to analyze the risk of invasion of contralateral mucosa in unilateral septal involvement of cancer and to risk stratify patients.

Methods: Retrospective chart review of patients with histologically proven malignancy with unilateral septal involvement and absence of gross septal tumor involvement on the contralateral side were included.

Results: Among 40 patients, majority (55%) belonged to sixth and seventh decade. The most common type was squamous cell carcinoma (63%). Approximately one-fourth (23%) showed microscopic contralateral invasion. Females (OR 12; 95% CI 2.01-71.35) and patients with septal bone invasion (OR 28.5; CI 3.35-242.0) had a higher risk of developing contralateral mucosal invasion.

Conclusion: Complete resection of contralateral mucosa is preferred in areas along the bony septum. When complete resection is not performed, intraoperative frozen section is strongly recommended.
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http://dx.doi.org/10.1002/hed.25870DOI Listing
October 2019

Effect of uvulopalatopharyngoplasty (UPPP) on atherosclerosis and cardiac functioning in obstructive sleep apnea patients.

Acta Otolaryngol 2019 Sep 3;139(9):793-797. Epub 2019 Jul 3.

a Department of Otolaryngology Head & Neck Surgery, Beijing Anzhen Hospital, Capital Medical University , Beijing , China.

Obstructive sleep apnea OSA) is associated with several cardiovascular comorbidities including hypertension, arteriosclerosis, and heart failure. Uvulopalatopharyngoplasty (UPPP) is a frequently performed surgical treatment for OSA. To analyze if UPPP can improve cardiac parameters associated with atherosclerosis and reduce the cardiac burden in OSA patients. A prospective cohort study was performed at a single tertiary care center where OSA patients undergoing UPPP were evaluated. Preoperative and 6-month postoperative cardiac parameters namely carotid artery intima-media thickness (CIMT), arterial stiffness parameters, echocardiography, and polysomnography (PSG) results were compared. Fifty three patients were included in the study. The success and response rate of UPPP was 60.4%. Following the surgery, significant reduction in arterial stiffness index (β) (12.4 ± 4.1 vs. 11.2 ± 4.0,  = .01), and elasticity modulus (Ep) (172.8 ± 68.3 vs. 156.6 ± 55.3,  = .05) was noticed. Additionally, echocardiographic parameters namely velocity across aortic valve (121.9 ± 22.9 vs. 109.4 ± 17.7,  = .01) and velocity across pulmonary valve (107.4 ± 16.4 vs. 94.2 ± 16.9,  < .01) significantly decreased following UPPP. UPPP significantly improves parameters related to carotid atherosclerosis and has the potential to reduce cardiac burden in OSA patients.
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http://dx.doi.org/10.1080/00016489.2019.1633475DOI Listing
September 2019

Evaluation of cranial base repair techniques utilizing a novel cadaveric CPAP model.

Int Forum Allergy Rhinol 2019 07 12;9(7):795-803. Epub 2019 Feb 12.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Although recent guidelines for obstructive sleep apnea recommend early postoperative use of continuous positive airway pressure (CPAP) after endonasal skull base surgery, the time of initiation of CPAP is unclear. In this study we used a novel, previously validated cadaveric model to analyze the pressures delivered to the cranial base and evaluate the effectiveness of various repair techniques to withstand positive pressure.

Methods: Skull base defects were surgically created in 3 fresh human cadaver heads and repaired using 3 commonly used repair techniques: (1) Surgicel™ onlay; (2) dural substitute underlay with dural sealant onlay; and (3) dural substitute underlay with nasoseptal flap onlay with dural sealant. Pressure microsensors were placed in the sphenoid sinus and sella, both proximal and distal to the repair, respectively. The effectiveness of each repair technique against various CPAP pressure settings (5-20 cm H O) was analyzed.

Results: Approximately 79%-95% of positive pressure administered reached the sphenoid sinus. Sellar pressure levels varied significantly across the 3 repair techniques and were lowest after the third technique. "Breach" points (CPAP settings at which sellar repair was violated) were lowest for the first group. All 3 specimens showed a breach after the first repair technique. For the second repair technique, only a single breach was created in 1 specimen at 20 cm H O. No breaches were created in the third group.

Conclusion: Different skull base repair techniques have varying ability to withstand CPAP. Both second and third repair techniques performed in a nearly similar fashion with regard to their ability to withstand positive pressure ventilation.
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http://dx.doi.org/10.1002/alr.22313DOI Listing
July 2019

Biphenotypic Sinonasal Sarcoma-Case Report and Review of Clinicopathological Features and Diagnostic Modalities.

J Neurol Surg B Skull Base 2019 Feb 16;80(1):51-58. Epub 2018 Jul 16.

Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States.

 Biphenotypic sinonasal sarcoma is a recently described malignancy showing dual differentiation with both myogenic and neural elements. Due to its histologic similarities to other sinonasal malignancies, it is a diagnostic challenge.  The main purpose of this article is to report a case of biphenotypic sinonasal sarcoma and to consolidate data and provide a comprehensive review regarding pathological differences between biphenotypic sarcoma and other sinonasal malignancies and diagnostic modalities used for biphenotypic sarcoma.  A systematic review of all cases of biphenotypic sinonasal sarcoma was performed using electronic databases (PubMed and Medline). Data collected included age, gender, symptoms, sub-site of origin, immunophenotyping, metastasis, recurrence, treatment, duration of follow-up, and survival outcomes.  Ninety-five cases of biphenotypic sarcoma were found with mean age at diagnosis of 52.36 years (range, 24-87 years). Female to male ratio was 2.27:1. Extra-sinonasal extension was present in 28%. Immunophenotyping revealed that S-100 and SMA (smooth muscle actin) were consistently positive, while SOX-10 was consistently negative. PAX3-MAML3 fusion [t (2; 4) (q35; q31.1)] was the most common genetic rearrangement. Surgical excision with or without adjuvant radiotherapy was the most frequent treatment modality used. Recurrence was observed in 32% of cases with follow-up. None of the cases reported metastasis. Three patients had died at the time of publication that included one case with intracranial extension.  Biphenotypic sarcoma is distinct sinonasal malignancy with unique clinicopathological features. Testing involving a battery of myogenic and neural immunomarkers is essential for diagnostic confirmation and is a clinically useful endeavor when clinical suspicion is high.
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http://dx.doi.org/10.1055/s-0038-1667146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365237PMC
February 2019

A cadaveric model for measuring sinonasal continuous positive airway pressure-a proof-of-concept study.

Int Forum Allergy Rhinol 2019 02 15;9(2):197-203. Epub 2018 Nov 15.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Obstructive sleep apnea is a common respiratory disorder that can have negative effects on health and quality of life. Positive pressure therapy (CPAP) is the primary treatment. There is a lack of consensus on the risk of postoperative CPAP after endoscopic sinus or skull base surgery. We present a proof-of-concept cadaver model for measuring sinonasal pressure delivered by CPAP.

Methods: Three fresh cadaver heads were prepared by removing the calvaria and brain. Sphenoidotomies were made and sellar bone was removed. Pressure sensors were placed in the midnasal cavity, sphenoid sinus, and sella. CPAP was applied and the delivered pressure was recorded at increasing levels of positive pressure. Paired t tests and intraclass correlation coefficients were used to analyze results.

Results: Increases in positive pressure led to increased pressure recordings for all locations. Nasal cavity pressure was, on average, 81% of delivered CPAP. Pressure was highest in the sphenoid sinus. The effect of middle turbinate medialization on intrasphenoid pressure was not statistically significant in 2 heads. Intrasellar pressure was 80% of delivered CPAP with lateralized turbinates and 84% with medialized turbinates. Pressure recordings demonstrated excellent reliability for all locations. All heads developed non-sellar-based cranial base leaks at higher pressures. Cribriform region leaks were successfully sealed with DuraSeal®.

Conclusion: Our proof-of-concept cadaver model represents a novel approach to measure pressures delivered to the nasal cavity and anterior skull base by CPAP. With further study, it may have broader clinical application to guide the safe postoperative use of CPAP in this population.
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http://dx.doi.org/10.1002/alr.22235DOI Listing
February 2019

Do Otolaryngology Patients Show Gender Preference When Choosing a Surgeon? - A Quantitative and Qualitative Analysis.

Int Arch Otorhinolaryngol 2018 Oct 12;22(4):404-407. Epub 2018 Apr 12.

Department of Otorhinolaryngology and Head and Neck Surgery, Jaypee Hospital, Noida, India.

 Otorhinolaryngology has always been considered a gender-neutral specialty, whereas in several other specialties, such as obstetrics, gynecology and urology, gender preference has been consistently shown by patients when choosing their treating surgeon. To date, no study has been performed to analyze whether this practice of gender preference is prevalent in otorhinolaryngology patients too.  To identify if gender preference exists in the field of otorhinolaryngology, specifically in its four subspecialties, namely otology, pediatric otolaryngology, laryngology and head and neck surgery.  Patients attending our outpatient department were asked to complete a preformed proforma. The pro forma consisted of two parts, demographic details of the subjects and gender preference in the following subspecialties: otology, pediatric otolaryngology, laryngology and head and neck oncosurgery.  A total of 1,112 subjects took part in the study, out of which 1,089 subjects were included in the final analysis. Female gender preference was highest in the field of pediatric otolaryngology, while male preference was highest for head and neck oncosurgery.  Though otorhinolaryngology and head and neck surgery has been considered a gender-neutral field, subspecialties of this field show considerable gender preference.
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http://dx.doi.org/10.1055/s-0038-1641165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197971PMC
October 2018

Oral sampling methods are associated with differences in immune marker concentrations.

Laryngoscope 2018 06 24;128(6):E214-E221. Epub 2017 Nov 24.

Milken Institute of Public Health, George Washington University, Washington, District of Columbia, U.S.A.

Objective: To determine whether the concentration and distribution of immune markers in paired oral samples were similar.

Study Type: Clinical research.

Study Design: Cross-sectional study.

Methods: Paired saliva and oral secretions (OS) samples were collected. The concentration of immune markers was estimated using Luminex multiplex assay (Thermo Fisher Scientific, Waltham, MA). For each sample, the concentration of respective immune markers was normalized to total protein present and log-transformed. Median concentrations of immune markers were compared between both types of samples. Intermarker correlation in each sampling method and across sampling methods was evaluated.

Results: There were 90 study participants. Concentrations of immune markers in saliva samples were significantly different from concentrations in OS samples. Oral secretions samples showed higher concentrations of immunoregulatory markers, whereas the saliva samples contained proinflammatory markers in higher concentration.

Conclusion: The immune marker profile in saliva samples is distinct from the immune marker profile in paired OS samples.

Level Of Evidence: 2b. Laryngoscope, 128:E214-E221, 2018.
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http://dx.doi.org/10.1002/lary.27002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5967988PMC
June 2018

Is the Voice of Professional Voice Users With no Vocal Cord Lesions Similar to That of Non Professional Voice Users?

J Voice 2019 Jan 24;33(1):66-72. Epub 2017 Oct 24.

Department of Otolaryngology, Head, and Neck Surgery, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India.

Objective: The objective of this study was to analyze if the voice of professional voice users (PVU) is comparable with that of a nonprofessional voice users (NPVUs), both of whom have no obvious vocal cord lesions.

Materials And Methods: Fifty professional and 50 NPVUs with no obvious vocal fold pathologies underwent voice analysis and videostroboscopic study, and various parameters were analyzed.

Results: Majority of the participants were found to be less than 40 years. Teachers formed the largest group (40%) of PVUs. PVUs had a significantly higher incidence of voice-related complaints compared with NPVUs. The former group also showed a higher deviation from the normative data. A significant influence of gender and the duration of work experience was also observed among PVUs.

Conclusions: The voice of an apparently normal PVU is not similar to that of an apparently normal NPVU. Female PVUs and PVUs with a longer duration of work experience show the highest deviation from normative data.
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http://dx.doi.org/10.1016/j.jvoice.2017.09.004DOI Listing
January 2019

Paediatric oral submucous fibrosis - The neglected pre-malignancy of childhood.

Int J Pediatr Otorhinolaryngol 2017 Jun 28;97:55-60. Epub 2017 Mar 28.

Jaypee Hospital, Noida 201301, India.

Oral submucous fibrosis in children is one of the devastating consequences of arecanut addiction in children. Arecanut is the fourth commonest psychoactive agents used worldwide. However, regrettably, unlike other addictions like tobacco and alcohol, its use in children has become socially acceptable atleast in a few countries. Consequently, children as young as two years have been noticed to be addicted to arecanuts. It has been a menace in most Asian countries and with increasing population migration, this has picked up even in the west. In order to understand the social factors leading to arecanut addiction in children and prognostic outcomes of paediatric oral submucous fibrosis, this review has been undertaken.
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http://dx.doi.org/10.1016/j.ijporl.2017.03.029DOI Listing
June 2017

Speaking and Nonspeaking Voice Professionals: Who Has the Better Voice?

J Voice 2018 Jan 18;32(1):45-50. Epub 2017 Apr 18.

Maulana Azad Medical College, New Delhi, Delhi, India.

Introduction: Voice professionals can be classified into two major subgroups: the primarily speaking and the primarily nonspeaking voice professionals. Nonspeaking voice professionals mainly include singers, whereas speaking voice professionals include the rest of the voice professionals. Although both of these groups have high vocal demands, it is currently unknown whether both groups show similar voice changes after their daily voice use. Comparison of these two subgroups of voice professionals has never been done before.

Aim: This study aimed to compare the speaking voice of speaking and nonspeaking voice professionals with no obvious vocal fold pathology or voice-related complaints on the day of assessment.

Methodology: After obtaining relevant voice-related history, voice analysis and videostroboscopy were performed in 50 speaking and 50 nonspeaking voice professionals.

Results: Speaking voice professionals showed significantly higher incidence of voice-related complaints as compared with nonspeaking voice professionals. Voice analysis revealed that most acoustic parameters including fundamental frequency, jitter percent, and harmonic-to-noise ratio were significantly higher in speaking voice professionals, whereas videostroboscopy did not show any significant difference between the two groups.

Conclusion: This is the first study of its kind to analyze the effect of daily voice use in the two subgroups of voice professionals with no obvious vocal fold pathology. We conclude that voice professionals should not be considered as a homogeneous group. The detrimental effects of excessive voice use were observed to occur more significantly in speaking voice professionals than in nonspeaking voice professionals.
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http://dx.doi.org/10.1016/j.jvoice.2017.03.003DOI Listing
January 2018

Adenoid cystic carcinoma of the base of tongue: A population-based study.

Am J Otolaryngol 2017 May - Jun;38(3):279-284. Epub 2017 Jan 18.

Department of Otolaryngology, Head & Neck and Skull Base Surgery, Boston Medical Center, Boston, MA, United States. Electronic address:

Background: The objective was to assess demographic and survival patterns in patients with adenoid cystic carcinoma of the base of tongue.

Methods: Patients were extracted from the Surveillance, Epidemiology and End Results (SEER) database from 1973 through 2012 and were categorized by age, gender, race, historical stage A, and treatment. Incidence and survival were compared with Kaplan Meier curves and mortality hazard ratios.

Results: A total of 216 patients were included. After adjusting for age, gender, race and tumor-directed treatment, patients over the age of 70years had a significantly increased mortality [HR=2.847, 95% CI (1.499, 5.404) p=0.0014]. Furthermore mortality among patients with distant disease was significantly increased [HR=2.474 95% CI (1.459, 4.195) p=0.00008].

Conclusion: By examining the largest collection of patients we have demonstrated that there is a significant difference in mortality based on both the age at diagnosis and in the setting of distant disease.
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http://dx.doi.org/10.1016/j.amjoto.2017.01.010DOI Listing
April 2018
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