Publications by authors named "Christopher H Le"

14 Publications

  • Page 1 of 1

Development of a self-directed sinonasal surgical anatomy video curriculum: Phase 1 validation.

Int Forum Allergy Rhinol 2021 May 21. Epub 2021 May 21.

Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, AZ.

Background: Sinusitis is a common outpatient diagnosis made by physicians and is a reason for referral to otolaryngologists. A foundation in basic sinonasal anatomy is critical in understanding sinus pathophysiology and avoiding complications. Our objective in this study was to develop and to validate a self-directed surgical anatomy video for medical students.

Methods: Two multimedia videos were developed highlighting sinonasal anatomy. In Video 1 we included audio narration and radiologic imaging. Video 2 incorporated highlighted images from a sinus surgery video. An assessment was developed to test sinonasal anatomy landmarks, spatial recognition of structures, and their clinical relevance. An expert panel of rhinologists scored face and content validity of the curriculum videos and assessment. Factor analysis was used to separate questions into face and content validity domains, and a one-sample t test was performed.

Results: The panel scored face validity (Videos 1 and 2: 4.4/5) and content validity (Video 1: 4.5/5, 0.83; Video 2: 4.3/5, 0.75) significantly higher than a neutral response. There were no statistical differences for face or content validity between videos. The assessment was rated suitable (29%) or very suitable (57%) for testing basic sinonasal surgical anatomy, and the majority (71%) of respondents agreed (14%) or strongly agreed (57%) that the assessment thoroughly covered the sinus anatomy content with which medical students should be familiar.

Conclusion: We have developed two videos and an assessment that highlight and test sinonasal anatomy. Future studies will aim to identify whether the use of a self-directed video curriculum improves sinonasal anatomy awareness and whether incorporation of surgical endoscopic videos augments training.
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http://dx.doi.org/10.1002/alr.22814DOI Listing
May 2021

A Comparative Analysis of Mucormycosis in Immunosuppressed Hosts Including Patients with Uncontrolled Diabetes in the Southwest United States.

Am J Med 2021 May 8. Epub 2021 May 8.

Division of Infectious Diseases.

Background: Mucormycosis (zygomycosis) is an invasive fungal infection that carries a high risk of morbidity and mortality. Uncontrolled diabetes mellitus and other immunocompromising conditions are risk factors for mucormycosis development. We here describe the differences in characteristics and outcomes of mucormycosis among solid organ transplant, hematological malignancy, and diabetes mellitus groups at our institution.

Methods: We conducted a retrospective chart review over the period of 2009-2020, with identifying patients using the International Classification of Diseases, Ninth and Tenth Revisions. Clinical, laboratory, and outcome data were collected.

Results: There were 28 patients identified: 7 solid organ transplant, 3 hematological malignancy, and 18 diabetes mellitus patients were included in the study. Three solid organ transplant patients experienced an episode of rejection, and another 3 had cytomegalovirus infection prior to presenting with mucormycosis. Four of seven solid organ transplant patients had a history of diabetes mellitus, but the median hemoglobin A1C was lower than in the diabetes mellitus group (6.3 vs 11.5; P = .006). The mortality rate difference between solid organ transplant and diabetes mellitus was not statistically significant: 2/7 (28.57%) vs 5/18 (27.78%); P = .66. Patients with bilateral disease (pulmonary or sinus) had significantly higher mortality (80% vs 13%, P = .008). There was no difference in mortality outcomes among the different types of antifungal therapies administered.

Conclusion: A multispecialty approach is imperative in mucormycosis therapy. While the underlying risk factors were different, the outcomes were comparable for the solid organ transplant and diabetes mellitus groups. Future larger and longitudinal studies are recommended.
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http://dx.doi.org/10.1016/j.amjmed.2021.04.008DOI Listing
May 2021

The effect of maxillary sinus antrostomy size on the sinus microbiome.

Int Forum Allergy Rhinol 2019 01 25;9(1):30-38. Epub 2018 Oct 25.

Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, AZ.

Background: The optimal maxillary antrostomy size to surgically treat sinusitis is not well known. In this study, we examined clinical metrics of disease severity and symptom scores, measured secreted inflammatory markers, and characterized the sinus microbiome to determine if there were significant differences in outcome between different maxillary ostial sizes.

Methods: Prospective randomized, single-blinded clinical trial enrolling 12 individuals diagnosed with recurrent acute or chronic rhinosinusitis. Each patient was blinded and randomized to receive minimal maxillary ostial dilation via balloon sinuplasty on 1 side vs a mega-antrostomy on the contralateral side. Data collected included symptom scores (20-item Sino-Nasal Outcome Test [SNOT-20]), endoscopy, and radiologic Lund-Mackay scores. During surgery and at their postoperative visit swabs were obtained from each maxillary sinus, and 16S DNA and inflammatory cytokine levels analyzed. The use of each patient as their own control allowed us to minimize confounding variables.

Results: There was statistically significant improvement in SNOT-20 symptom scores postoperatively in all patients. There were no significant differences between maxillary ostial size in postoperative endoscopy scores, cytokine profile, or bacterial burden. There were statistically significant differences in relative postoperative abundance of Staphylococcus, Lactococcus, and Cyanobacteria between the mega-antrostomy and mini-antrostomy.

Conclusions: The method used in surgical maxillary antrostomies had no effect on endoscopy scores or cytokine profiles. Microbiome analysis determined significant differences between the different antrostomy sizes in postoperative Staphylococcus, Lactococcus, and Cyanobacteria abundance. The clinical significance of these changes in the sinus microbiome are not known but may be a result of increased access to postoperative sinonasal irrigations.
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http://dx.doi.org/10.1002/alr.22224DOI Listing
January 2019

A prospective, randomized, single-blinded trial for improving health outcomes in rhinology by the use of personalized video recordings.

Int Forum Allergy Rhinol 2018 12 17;8(12):1406-1411. Epub 2018 Sep 17.

Department of Otolaryngology-Head and Neck Surgery, University of Arizona, Tucson, AZ.

Background: Clear patient-physician communication is critical in improving patient compliance, outcomes, and satisfaction. However, constraints of shortened clinic visits, patient anxiety, and poor recall can cause significant barriers to effective communication. We hypothesized that the ability to view patient-physician counseling videos at home would improve health outcomes.

Methods: Patients in a tertiary rhinology clinic were enrolled into a single-blinded prospective study after obtaining institutional review board (IRB) approval and informed consent. All enrollees had a short summary of their clinical encounter video-recorded with a tablet using Medical Memory, a Health Insurance Portability and Accountability Act (HIPAA)-compliant software system. Patients were randomized to receive access to their videos by our research coordinator, and outcomes included questionnaires at the first postoperative visit to assess patient recall and satisfaction.

Results: A total of 101 patients were enrolled. Half of those with video access watched the video at least once, on average 3.44 times. Of those without access, 90% would have liked the option. Those with video access had a higher percentage of correct answers to questions regarding surgical risk and extent of surgery; however, there was no significant difference between the 2 groups.

Conclusion: Our results show that patients in both groups were enthusiastic about this technology and often shared their videos with family and friends. Video-recordings of physician-patient encounters may be a possible solution to improve physician-patient communication.
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http://dx.doi.org/10.1002/alr.22145DOI Listing
December 2018

Complications of Advanced Kadish Stage Esthesioneuroblastoma: Single Institution Experience and Literature Review.

Cureus 2017 May 12;9(5):e1245. Epub 2017 May 12.

University of Arizona.

Introduction: In esthesioneuroblastoma, greater disease extent and Kadish staging correlate with greater recurrence, complications, and mortality. These advanced stage malignancies require extensive resections and aggressive adjuvant therapy. This increases the risk of complications such as cerebrospinal fluid leak, neurologic deficits, and osteomyelitis. We present our case series and then analyze the literature to ascertain whether advanced stage tumors corresponds to greater rates of complications.

Methods: A retrospective review of consecutive patients with histologically-proven esthesioneuroblastoma who were aggressively managed at our institution was performed. This was followed by an extensive literature search of published original data, in large series from 2006-2016, where both surgery and adjuvant therapy were used for the treatment of esthesioneuroblastoma.

Results : Single institution review revealed eight patients with esthesioneuroblastoma, half with advanced Kadish staging. All Kadish A patients ( Kadish A: confined to nasal cavity) underwent endoscopic approaches alone, while Kadish C patients (Kadish C: extends beyond nasal cavity and paranasal sinuses) and D patients (Kadish D: lymph node or distant metastases) underwent craniofacial approaches, while all patients received post-operative adjuvant therapies. Complications such as cerebrospinal fluid (CSF) leak, seizures, meningitis, and abscess only occurred in high Kadish stage patients. Literature review demonstrated a higher proportion of advanced Kadish stage cases correlated with increasing rates of pneumocephalus, infection, and recurrence. A higher proportion of Kadish C and D tumors was inversely correlated with CSF leak rate and overall survival.

Discussion: Advanced stage tumors are often associated with a higher incidence of adverse events up to 33%, both due to disease burden and treatment effect. There is increasing use of endoscopy and neoadjuvant therapy, which have the potential to decrease complication rates.

Conclusion : Advanced Kadish stage esthesioneuroblastoma necessitates meticulous surgical resection and aggressive adjuvant therapies, together, these increase the likelihood of adverse events, including CSF leak, neurologic deficits, and infections, and may represent the real morbidity cost of radically treating these tumors to achieve an improvement in overall survival. In selected patients, less-invasive approaches or neo-adjuvant therapies can be used without compromising on a curative resection.
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http://dx.doi.org/10.7759/cureus.1245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467981PMC
May 2017

Complex Skull Base Reconstructions in Kadish D Esthesioneuroblastoma: Case Report.

J Neurol Surg Rep 2017 Apr;78(2):e86-e92

Division of Neurosurgery, Department of Surgery, University of Arizona, Tucson, Arizona, United States.

 Advanced Kadish stage esthesioneuroblastoma requires more extensive resections and aggressive adjuvant therapy to obtain adequate disease-free control, which can lead to higher complication rates. We describe the case of a patient with Kadish D esthesioneuroblastoma who underwent multiple surgeries for infectious, neurologic, and wound complications, highlighting potential preventative and salvage techniques.  A 61-year-old man who presented with a large left-sided esthesioneuroblastoma, extending into the orbit, frontal lobe, and parapharyngeal nodes. He underwent margin-free endoscopic-assisted craniofacial resection with adjuvant craniofacial and cervical radiotherapy and concomitant chemotherapy. He then returned with breakdown of his skull base reconstruction and subsequent frontal infections and ultimately received 10 surgical procedures with surgeries for infection-related issues including craniectomy and abscess evacuation. He also had surgeries for skull base reconstruction and CSF leak, repaired with vascularized and free autologous grafts and flaps, synthetic tissues, and CSF diversion.  Extensive, high Kadish stage tumors necessitate radical surgical resection, radiation, and chemotherapy, which can lead to complications. Ultimately, there are several options available to surgeons, and although precautions should be taken whenever possible, risk of wound breakdown, leak, or infection should not preclude radical surgical resection and aggressive adjuvant therapies in the treatment of esthesioneuroblastoma.
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http://dx.doi.org/10.1055/s-0037-1601877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418125PMC
April 2017

The Role of Targeted Therapy in the Management of Sinonasal Malignancies.

Otolaryngol Clin North Am 2017 Apr;50(2):443-455

Department of Otolaryngology, University of Kansas School of Medicine, 3901 Rainbow Blvd, MS 3010, Kansas City, KS 66160, USA. Electronic address:

Cancers develop secondary to genetic and epigenetic changes that provide the cell with a survival advantage that promotes cellular immortality. Malignancy arises when tumors use mechanisms to evade detection and destruction by the immune system. Many malignancies seem to elicit an immune response, yet somehow manage to avoid destruction by the cells of the immune system. Cancers may evade this immune response by numerous mechanisms. Several targeted immune therapies are available that block some of these inhibitory signals and enhance the cell-mediated immune response. Many of these agents hold significant promise for future treatment of sinonasal and ventral skull base malignancies.
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http://dx.doi.org/10.1016/j.otc.2016.12.016DOI Listing
April 2017

Paranasal sinus size is decreased in CFTR heterozygotes with chronic rhinosinusitis.

Int Forum Allergy Rhinol 2017 03 17;7(3):256-260. Epub 2016 Nov 17.

Department of Otolaryngology, University of Arizona, Tucson, AZ.

Background: Cystic fibrosis (CF) heterozygotes with a single mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene are at significantly higher risk to develop chronic rhinosinusitis (CRS). However the reasons why remain unknown. We tested the hypothesis that CFTR heterozygotes would have smaller sinus volumes than healthy controls. To exclude sinus disease as a confounding factor we also assessed paranasal sinus volume in those with CRS, but without known CFTR mutations.

Methods: A total of 131 adults of white Northern European and Latino origin were recruited: 81 diagnosed with CRS and 50 healthy controls. Subjects were genotyped for 9 common CFTR mutations covering >80% of mutation prevalence. Those with CRS were separated by CFTR mutational status and matched demographically to healthy controls. Three-dimensional sinus volume, mucosal opacification, and skull volume were quantified to obtain the percentage of pneumatization and extent of mucosal disease in each sinus. Twenty-item Sino-Nasal Outcome Test (SNOT-20) and endoscopy scores were also analyzed.

Results: In individuals diagnosed with CRS we identified 7 CFTR heterozygotes (8.64%); no CFTR mutations were identified in our healthy controls. There were no significant differences between the 3 matched groups other than sinus pneumatization. The frontal and maxillary sinuses were significantly smaller in CFTR heterozygotes with CRS compared to CFTR wild-type subjects with or without disease.

Conclusion: CFTR heterozygotes with CRS have significantly smaller frontal and maxillary sinus size compared to those without mutations, irrespective of disease state. This sinus hypoplasia may contribute to impaired mucus clearance and chronic sinus disease development.
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http://dx.doi.org/10.1002/alr.21874DOI Listing
March 2017

Incidence of intracranial radiation necrosis following postoperative radiation therapy for sinonasal malignancies.

Laryngoscope 2016 11 14;126(11):2445-2450. Epub 2016 Jun 14.

Department of Otolaryngology-Head and Neck Surgery, University of Arizona, College of Medicine, Tucson, Arizona, U.S.A.

Objectives/hypothesis: Surgery and postoperative radiation therapy are commonly used in the treatment of advanced sinonasal cancer. However, post-treatment radiation changes to the brain often mimic radiologic findings suggestive of tumor recurrence, leading to potential unnecessary intracranial biopsies. The objective of this study was to determine clinical factors that predict signs of tumor recurrence versus radiation necrosis in post-therapy sinonasal malignancies with intracranial extension.

Study Design: Retrospective study.

Methods: Twenty-six patients with sinonasal malignancy with intracranial extension underwent surgery and radiation ± chemotherapy between 2010 and 2014 at the University of Arizona. We analyzed sinonasal cancer type, stage, total radiation dosimetry, time until imaging changes, surgical pathology, associated imaging, and patient demographics.

Results: Thirteen of 26 patients had postoperative imaging changes seen on surveillance magnetic resonance imaging (MRI). Five were deemed to have tumor recurrence due to new metastasis seen on positron emission tomography/computed tomography scan. Four patients were observed with serial imaging that confirmed pseudoprogression. In four patients, there was sufficient concern due to persistent MRI changes, which prompted surgical biopsy, and only one of them was positive for tumor recurrence. Factors that favored tumor recurrence included faster onset of imaging changes on MRI (55 vs. 186 days, P < .05).

Conclusions: Intracranial tumor recurrence can be difficult to distinguish between radiation necrosis in sinonasal cancers treated with surgery and postoperative radiation ± chemotherapy. Patients with sub-total resection and rapid onset of MRI changes in postsurveillance scans are more likely to have tumor recurrence versus radiation necrosis. Future imaging techniques or tests that investigate tumor biomarkers are necessary to prevent unnecessary biopsies.

Level Of Evidence: 4 Laryngoscope, 126:2445-2450, 2016.
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http://dx.doi.org/10.1002/lary.26106DOI Listing
November 2016

Practice patterns in endoscopic dacryocystorhinostomy: survey of the American Rhinologic Society.

Int Forum Allergy Rhinol 2016 09 6;6(9):990-7. Epub 2016 Apr 6.

Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA.

Background: The introduction of advanced endoscopic techniques has facilitated significant growth in endoscopic dacryocystorhinostomy (EnDCR). The purpose of this study is to evaluate clinical practice patterns of otolaryngologists performing EnDCR.

Methods: A 25-item survey was electronically disseminated to the American Rhinologic Society (ARS) membership from November 17, 2014 to December 14, 2014. The target group encompassed 1157 ARS members.

Results: A total of 85 (7.3%) physicians completed the survey. EnDCR was performed by 87% of respondents. The annual average number of EnDCR cases ranged from 1 to 10 in 65% of respondents, 11 to 25 in 15%, 26 to 50 in 6%, and >50 in 1%. A total of 48% of respondents had some to a lot of DCR exposure during training, and 60% had completed a rhinology fellowship. Respondents frequently perform preoperative nasal endoscopy and computed tomography (CT) imaging, but very infrequently perform ophthalmologic workup. Lacrimal stents were used often or always in 80%, with 38% keeping stents in place for 6 to 8 weeks. The mucosal flap preservation technique was used often or always in 40%. Topical antimetabolites were used often or always in only 1%. Ophthalmology was present in most cases to perform lacrimal intubation. Postoperative antibiotics, topical ophthalmic steroids, and oral steroids were prescribed often or always in 62%, 47%, and 23%, respectively. Postoperative endoscopic debridement was performed often or always in 69%. A total of 81% of respondents followed DCR patients for >2 months, with 17% following these patients for >1 year.

Conclusion: There is widespread integration of EnDCR procedures into rhinologic clinical practice among respondents. EnDCR practice patterns demonstrate moderate variation. In conjunction with evidence-based medicine, these trends can highlight areas of controversy and help advance patient care.
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http://dx.doi.org/10.1002/alr.21759DOI Listing
September 2016

Endoscopic resection of maxillary sinus keratocystic odontogenic tumors.

Laryngoscope 2016 10 12;126(10):2216-9. Epub 2016 Mar 12.

Department of Otolaryngology-Head and Neck Surgery, the University of Arizona College of Medicine, Tucson, Arizona, U.S.A.

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http://dx.doi.org/10.1002/lary.25920DOI Listing
October 2016

Novel techniques for the diagnosis of Ménière's disease.

Curr Opin Otolaryngol Head Neck Surg 2013 Oct;21(5):492-6

Department of Otolaryngology - Head and Neck Surgery, University of California Davis Medical Center, Sacramento, California 95817, USA.

Purpose Of Review: This review will consider the newly developed and emerging diagnostic techniques with real or potential clinical application to the diagnosis of Ménière's disease.

Recent Findings: Several new diagnostic modalities have been introduced, which have the potential to help diagnose endolymphatic hydrops. These include cervical and ocular vestibular evoked myogenic potentials, cochlear hydrops analysis masking procedures, and three-dimensional fluid-attenuated inversion recovery MRI following intratympanic instillation of gadolinium.

Summary: Diagnosis of Ménière's disease has classically been of a clinical rather than a procedural nature. Despite the many recent advances in diagnostic testing which show potential applicability for aiding in diagnosis of Ménière's disease, each has limitations which prevent immediate utility. For now, Ménière's disease remains best diagnosed through the standard American Academy of Otolaryngology - Head and Neck Surgery clinical inclusionary and exclusionary criteria.
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http://dx.doi.org/10.1097/MOO.0b013e328364869bDOI Listing
October 2013