Publications by authors named "Edward C Kuan"

156 Publications

Intralesional Candida antigen injection as a treatment modality for sinonasal squamous papilloma.

Int Forum Allergy Rhinol 2021 May 28. Epub 2021 May 28.

Department of Dermatology, University of California Irvine, Irvine, California, USA.

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http://dx.doi.org/10.1002/alr.22825DOI Listing
May 2021

The association of frailty, age, and ASA classification with postoperative outcomes in endoscopic sinus surgery.

Int Forum Allergy Rhinol 2021 May 28. Epub 2021 May 28.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA.

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http://dx.doi.org/10.1002/alr.22829DOI Listing
May 2021

Association Between Olfactory Dysfunction and Critical Illness and Mortality in COVID-19: A Meta-analysis.

Otolaryngol Head Neck Surg 2021 May 25:1945998211017442. Epub 2021 May 25.

Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California, USA.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/01945998211017442DOI Listing
May 2021

The influence of facility volume on patient treatments and survival outcomes in nasopharyngeal carcinoma.

Head Neck 2021 May 17. Epub 2021 May 17.

Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, USA.

Background: This study evaluates the influence of facility case-volume on nasopharyngeal carcinoma (NPC) treatments and overall survival (OS).

Methods: The 2004-2015 National Cancer Database was queried for patients with NPC receiving definitive treatment.

Results: A total of 8260 patients (5-year OS: 63.4%) were included. The 1114 unique facilities were categorized into 854 low-volume (treating 1-8 patients), 200 intermediate-volume (treating 9-23 patients), and 60 high-volume (treating 24-187 patients) facilities. Kaplan-Meier log-rank analysis demonstrated significantly improved OS with high-volume facilities (p < 0.001). On cox proportional-hazard multivariate regression after adjusting for age, sex, income, insurance, comorbidity index, histology, AJCC clinical stage, and treatment type, high-volume facilities were associated with lower mortality risk than low-volume (HR = 0.865, p = 0.019) and intermediate-volume facilities (HR = 0.916, p = 0.004). Propensity score matching analysis confirmed this association (p < 0.001).

Conclusion: Higher facility volume was an independent predictor of improved OS in NPC, suggesting a possible survival benefit of referrals to high-volume medical centers.
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http://dx.doi.org/10.1002/hed.26739DOI Listing
May 2021

Determinants of Survival in Skull Base Osteosarcoma: A National Cancer Database Study.

World Neurosurg 2021 May 8. Epub 2021 May 8.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, USA; Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA. Electronic address:

Objective: Skull base osteosarcoma is a rare and aggressive tumor that is most commonly treated with primary surgical resection and adjuvant chemoradiation. Using the National Cancer Database, we analyzed demographic and clinical prognosticators for overall survival (OS).

Methods: The National Cancer Database was queried for cases of histologically confirmed skull base osteosarcoma treated between 2004 and 2015, excluding patients receiving palliation or having <1 month of follow-up. A total of 314 patients treated with surgery alone (n = 82), surgery with adjuvant radiotherapy (n = 35), surgery with chemotherapy (n = 114), or trimodality therapy (n = 56) were identified. The χ test for categorical variables, Cox proportional hazards models, and Kaplan-Meier log-rank analysis were used to test associations with treatment, OS, and survival time.

Results: None of the studied demographic characteristics (age, sex, race, overall health) and socioeconomic factors (income and average regional education) were associated with OS (none P < 0.05). Treatment modalities also did not show a significant association with OS (none P < 0.05). Certain tumor characteristics showed an association with OS, with fibroblastic and Paget histologic subtypes (each P = 0.003), poorly differentiated tumor grade (P = 0.03), and tumor size >5 cm (P = 0.045) associated with poorer OS.

Conclusions: Tumor histologic subtype, advanced tumor grade, and greater tumor size are predictors of worse OS in skull base osteosarcoma. No significant differences in OS were identified based on treatment modality, which warrants further investigation.
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http://dx.doi.org/10.1016/j.wneu.2021.04.135DOI Listing
May 2021

Association Between 5-Item Modified Frailty Index and Short-term Outcomes in Complex Head and Neck Surgery.

Otolaryngol Head Neck Surg 2021 May 11:1945998211010443. Epub 2021 May 11.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA.

Objectives: To evaluate the impact of preoperative frailty on short-term outcomes following complex head and neck surgeries (HNSs).

Study Design: Cross-sectional database analysis.

Setting: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods: The 2005 to 2017 ACS-NSQIP was queried for patients undergoing complex HNS. Five-item modified frailty index (mFI) was calculated based on functional status and history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and chronic hypertension.

Results: A total of 2786 patients (73.1% male) with a mean age of 62.0 ± 11.6 years were included. Compared to nonfrail patients (41.2%), patients with mFI ≥1 (58.8%) had shorter length of operation ( = .021), longer length of stay (LOS) ( < .001), and higher rates of 30-day reoperation ( = .009), medical complications ( < .001), discharge to nonhome facility (DNHF) ( < .001), and mortality ( = .047). These parameters remained statistically significant when compared across all individual mFI scores (all < .05). After adjusting for age, sex, race, body mass index, smoking, and American Society of Anesthesiologists score via multivariate logistic regression, patients with mFI ≥1 were significantly more likely to undergo reoperation (odds ratio [OR], 1.39), surgical complications (OR, 1.19), medical complications (OR, 1.55), prolonged LOS (OR, 1.29), and DNHF (OR, 1.56) (all < .05). Multivariate logistic regression also demonstrated that after adjusting for confounders, compared to patients with mFI = 1, patients with mFI = 2-5 (18.7%) were more likely to undergo shorter operations (OR, 0.74), have medical (OR, 1.46) or any complications (OR, 1.27), and have DNHF (OR, 1.62) (all < .05).

Conclusion: The 5-point mFI can independently predict short-term surgical outcomes following complex HNS. This simple and reliable metric can potentially lead to improved preoperative counseling and postoperative planning for complex HNS patients.
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http://dx.doi.org/10.1177/01945998211010443DOI Listing
May 2021

Characteristics and overall survival in pediatric versus adult pituitary adenoma: a National Cancer Database analysis.

Pituitary 2021 Apr 30. Epub 2021 Apr 30.

Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Drive South, Irvine, Orange, CA, 92868, USA.

Objective: Pituitary adenomas in the pediatric population are extremely rare, resulting in limited information in the literature on these patients. In this study, data from the National Cancer Database (NCDB) to compare pituitary adenoma clinical presentations, treatment management patterns, and overall survival between pediatric and adult patients.

Methods: The NCDB was queried for all cases of histologically confirmed pituitary adenoma treated between 2004 and 2015. Patients were primarily stratified as either pediatric (< 18 years) or adult (≥ 18 years). Patient demographics/socioeconomics and resulting outcomes were then compared.

Results: 1893 pediatric and 77,993 adult patients with pituitary adenomas were evaluated. Average tumor size for pediatric and adult patients was 13.6 ± 13.2 mm and 20.1 ± 13.1 mm, respectively (p < 0.001). Pediatric patients were more likely to undergo gross total resection, less likely to receive adjuvant radiation, more likely to receive medical therapy, more likely to undergo active surveillance, and exhibited improved 5-year and 10-year overall survival (OS) (all p < 0.001). Temporal analysis demonstrated a significant increase in endoscopic approach over time (from 48 to 65%) in the pediatric population (R = 0.722, p = 0.03). On univariate analysis in the pediatric population, African American race compared to Caucasians (HR: 5.85, 95% CI 1.79-19.2, p < 0.003), patients with government insurance compared to those with private insurance (HR: 5.07, 95% CI 1.31-19.6, p < 0.02) and uninsured patients compared to those with private insurance (HR: 14.4, 95% CI 2.41-86.5, p < 0.003) were associated with decreased OS. Lastly, patients who underwent GTR had improved OS compared to those who underwent subtotal resection (HR: 0.08, 95% CI 0.008-0.93, p < 0.04) in the pediatric population.

Conclusions: Compared to adults, children with pituitary adenomas more commonly underwent GTR, less frequently underwent adjuvant radiotherapy, more frequently underwent medical management and active surveillance, and had improved survival. Temporal analysis demonstrated increasing utilization of the endoscopic approach for surgical treatment of pediatric and adult pituitary adenoma patients.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s11102-021-01146-3DOI Listing
April 2021

Temporal patterns of nasal symptoms in patients with mild severity SARS-CoV-2 infection.

Am J Otolaryngol 2021 Apr 24;42(6):103076. Epub 2021 Apr 24.

Department of Otorhinolaryngology - Head & Neck Surgery, Rush University Medical Center, Chicago, IL, United States of America. Electronic address:

Background: No study to date has analyzed the progression of sinonasal symptoms over time in COVID-19 patients. The purpose of this study is to analyze the progression of sinonasal symptoms and risk factors for olfactory dysfunction in the mild severity COVID-19 patient.

Methods: An internet survey was used to assess sinonasal symptoms in patients with COVID-19. Changes in rhinologic domain and symptom-specific Sinonasal Outcome Test (SNOT-22) scores were compared at five time points: two weeks before diagnosis, at diagnosis, two weeks after diagnosis, four weeks after diagnosis, and six months after diagnosis.

Results: 521 responses were collected. Rhinologic domain SNOT-22 scores increased significantly (p < 0.001) to 8.94 at the time of diagnosis, remained elevated two weeks post-diagnosis (5.14, p = 0.004), and decreased significantly four weeks post-diagnosis (3.14, p = 0.004). Smell-specific SNOT-22 scores peaked at the time of diagnosis (2.05, p < 0.001), remained elevated two weeks after diagnosis (1.19, p < 0.001), and returned to baseline four weeks post-diagnosis (0.64, p > 0.999). Taste-specific SNOT-22 scores also peaked at diagnosis (2.06, p < 0.001), remained elevated two weeks after diagnosis (1.19, p < 0.001), and returned to baseline four weeks after diagnosis (0.71, p > 0.999). There were no significant differences in sense of smell or taste between 1-month and 6-month timepoints.

Conclusion: Sinonasal symptoms, particularly loss of smell and taste, may be important presenting symptoms in the mild severity COVID-19 patient. Our findings support incorporating these symptoms into screening protocols.

Level Of Evidence: 4.
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http://dx.doi.org/10.1016/j.amjoto.2021.103076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064817PMC
April 2021

Treatment Modalities and Survival Outcomes for Sinonasal Diffuse Large B-Cell Lymphoma.

Laryngoscope 2021 Apr 26. Epub 2021 Apr 26.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, U.S.A.

Objectives/hypothesis: This study utilizes a large population national database to comprehensively analyze prognosticators and overall survival (OS) outcomes of varying treatment modalities in a large cohort of sinonasal diffuse large B-cell lymphoma (SN-DLBCL) patients.

Study Design: Retrospective database study.

Methods: The National Cancer Database was queried for all SN-DLBCL cases diagnosed from 2004 to 2015. Kaplan-Meier log-rank test determined differences in OS based on clinical covariates. Cox proportional-hazards analysis was used to determine clinical and sociodemographic covariates predictive of mortality.

Results: A total of 2,073 SN-DLBCL patients were included, consisting of 48% female with a mean age of 66.0 ± 16.2 years. Overall, 82% of patients were Caucasian, 74% had early-stage disease, and 49% had primary tumors in the paranasal sinuses. Early-stage patients were more likely to receive multi-agent chemoradiotherapy compared to multi-agent chemotherapy alone (P < .001). Multivariable Cox proportional-hazards analysis revealed chemoradiotherapy to confer significantly greater OS improvements than chemotherapy alone (hazard ratio [HR]: 0.61; P < .001). However, subset analysis of late-stage patients demonstrated no significant differences in OS between these treatment modalities (P = .245). On multivariable analysis of chemotherapy patients treated post-2012, immunotherapy (HR = 0.51; P = .024) demonstrated significant OS benefits. However, subset analysis showed no significant advantage in OS with administering immunotherapy for late-stage patients (P = .326). Lastly, for all patients treated post-2012, those receiving immunotherapy had significantly improved OS compared to those not receiving immunotherapy (P < .001).

Conclusions: Treatment protocol selection differs between early- and late-stage SN-DLBCL patients. Early-stage patients receiving chemotherapy may benefit from immunotherapy as part of their treatment paradigm.

Level Of Evidence: III Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29584DOI Listing
April 2021

Pre-intervention SNOT-22 scores predict outcomes in aspirin exacerbated respiratory disease.

Am J Otolaryngol 2021 Mar 31;42(5):103025. Epub 2021 Mar 31.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States of America.

Purpose: This study evaluated whether stratified preoperative, pre- aspirin desensitization (AD) sinonasal symptom scores predict postoperative, post-AD outcomes in Aspirin exacerbated respiratory disease (AERD).

Materials And Methods: Retrospective chart review of patients with aspirin challenge-proven AERD who underwent endoscopic sinus surgery followed by AD was performed. Preoperative, postoperative/pre-AD, and postoperative/post-AD sinonasal symptom scores were collected (22-item Sino-Nasal Outcomes Test, SNOT-22). A longitudinal linear mixed-effects model was used for data analysis.

Results: Forty-seven patients (59.6% female) aged 48.0 ± 13.2 were included. Average time from surgery to AD was 70.0 ± 52.8 days. Preoperative SNOT-22 scores (n = 47) were divided into tertiles (cutoffs of 36 and 54 indicating mild [22.5 ± 13.7], moderate [44.3 ± 12.2], and severe [72.9 ± 19.7] disease). This corresponded to 12 (25.5%), 18 (38.3%), and 17 (36.2%) subjects being categorized into mild, moderate, and severe tertiles, respectively. Postoperative, pre-AD SNOT-22 in all disease groups decreased and were not significantly different (12.3 ± 13.7, 11.1 ± 12.2, 22.7 ± 19.7; p = 0.074). At short-term post-AD, only the severe group worsened (35.0 ± 20.3, p < 0.001), whereas other groups demonstrated negligible change (9.3 ± 14.3 and 14.4 ± 12.2). At long-term post-AD, all groups redemonstrated convergence in symptom scores (23.7 ± 20.9, 19.4 ± 15.4, and 31.0 ± 27.6, p = 0.304).

Conclusion: Preoperative SNOT-22 scores may be used as a predictor of postoperative, post-AD patient-reported outcomes in AERD. Patients with mild and moderate disease may derive benefit from surgery and AD alone, while those with severe disease may require additional interventions (e.g., biologics).
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http://dx.doi.org/10.1016/j.amjoto.2021.103025DOI Listing
March 2021

Characteristics and overall survival in pediatric versus adult esthesioneuroblastoma: A population-based study.

Int J Pediatr Otorhinolaryngol 2021 May 28;144:110696. Epub 2021 Mar 28.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA; Department of Neurological Surgery, University of California, Irvine, CA, USA. Electronic address:

Background: Esthesioneuroblastoma (ENB) is an uncommon sinonasal malignancy and is even less common in the pediatric population.

Objective: The purpose of this study is to compare characteristics and outcomes of ENB between adult and pediatric patients.

Methods: The National Cancer Database was queried for patients with histologically proven ENB of the nasal cavity and paranasal sinuses, and then baseline characteristics, treatment, and survival data compared between the pediatric (age < 18 years) and adult (age ≥ 18 years) populations.

Results: 1411 patients were identified, with 45 in the pediatric cohort and 1366 in the adult cohort. Ten-year overall survival (OS) in the pediatric cohort was improved compared to the adult cohort, 87% and 66%, respectively (p < 0.05). Adjuvant chemotherapy was more commonly utilized in the pediatric cohort (p < 0.001). Race was associated with decreased OS in the pediatric cohort (p = 0.013). Pediatric patients had shorter length of stay (p = 0.009) and lived closer to their provider (p = 0.044) than adult ENB patients.

Conclusion: Treatment of ENB in pediatric patients more commonly includes chemotherapy and more commonly occurs at academic medical centers. OS is improved in pediatric ENB compared to adults as well, but larger studies are necessary.
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http://dx.doi.org/10.1016/j.ijporl.2021.110696DOI Listing
May 2021

In Response to Recommendations for the Rising Otolaryngology Residency Programs' Social Media Presence.

Laryngoscope 2021 06 4;131(6):E1817. Epub 2021 Mar 4.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, U.S.A.

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http://dx.doi.org/10.1002/lary.29502DOI Listing
June 2021

Characteristics and overall survival in pediatric versus adult craniopharyngioma: a population-based study.

Childs Nerv Syst 2021 May 28;37(5):1535-1545. Epub 2021 Feb 28.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, 101 The City Drive South, Orange, CA, 92868-3201, USA.

Purpose: This study uses a large-population national database to describe the presenting clinical, sociodemographic, treatment, and clinical outcome differences between pediatric and adult craniopharyngiomas.

Methods: This study utilized the 2004-2015 National Cancer Database and was queried for all cases of craniopharyngioma. Multivariate Cox proportional-hazards analysis was used to determine clinical and sociodemographic factors associated with mortality. Kaplan-Meier log-rank test determined differences in overall survival (OS) time.

Results: The cohort consisted of 3638 patients, with 816 (22.4%) pediatric (≤ 18 years) patients. Pediatric patients presented with significantly higher frequency of large tumors (> 3 cm, 54.1 vs. 31.8%, p < 0.001), lower frequency of papillary subtype (0.9 vs. 11.5%, p < 0.001), and were exclusively treated at academic centers (100 vs. 73.4%, p < 0.001). Pediatric patients had significantly higher rates of adjuvant radiation (34.3 vs. 22.3%; p < 0.001), and had significantly lower 90-day mortality (1.6 vs. 4.9%; p < 0.001); however, no significant differences in extent of resection (p = 0.93), length of hospital stay (p = 0.53), and 30-day readmissions (p = 0.06) were observed between pediatric and adult patients. On Kaplan-Meier log-rank test, there were no significant differences in OS in pediatric patients receiving gross total resection (GTR), subtotal resection (STR), or STR + adjuvant radiation (p = 0.68). Lastly, when comparing endoscopic and open surgical approaches in pediatric patients, there were no significant differences in extent of surgical resection (p = 0.81), length of hospital stay (p = 0.54), 30-day readmissions (p = 0.22), and 90-day mortality (p = 0.80).

Conclusion: Craniopharyngioma has improved OS in pediatric compared to adult patients. Pediatric craniopharyngioma patients are best managed within multidisciplinary teams at academic centers with an individualized approach.
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http://dx.doi.org/10.1007/s00381-021-05094-yDOI Listing
May 2021

Chronic Sphenoiditis With Deep Neck Space Extension: Case Report With Review of the Literature and Postulated Mechanisms for Extracranial Extension.

Ear Nose Throat J 2021 Jan 20:145561321989453. Epub 2021 Jan 20.

Department of Otorhinolaryngology, 2468Rush University Medical Center, Chicago, IL, USA.

Isolated primary sphenoid sinusitis is a rare occurrence, estimated to make up less than 3% of sinus infections. The posterior anatomic location of the sphenoid makes treatment challenging when it becomes infected. Complications involving intracranial extension to surrounding structures often result in cranial nerve deficits due to their proximity. A single case of chronic sphenoiditis with direct extracranial extension into the prevertebral space is reported with a discussion on clinical presentation, diagnosis, and management. A 46-year-old female patient with diffuse headaches radiating into the neck and throat was evaluated in the office. Computed tomography demonstrated sphenoiditis with direct extension into the prevertebral space. Imaging revealed a purported route of direct extension through the clinoid and directly into the clivus to form an abscess in the longus colli muscle. The patient underwent endoscopic surgical management including drainage of the prevertebral abscess and has since made a full recovery. This is the first reported case of direct extension of sphenoiditis into the prevertebral space. The findings highlight the importance of aggressive treatment of chronic sphenoid infections to prevent detrimental complications. Computed tomography imaging proved an advantageous imaging modality to demonstrate bony erosion and sinus tracts from the skull base to the deep neck space.
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http://dx.doi.org/10.1177/0145561321989453DOI Listing
January 2021

Nasal Obstruction as a Potential Factor Contributing to Hypoxemia in Obstructive Sleep Apnea.

Nat Sci Sleep 2021 12;13:55-62. Epub 2021 Jan 12.

Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Purpose: This study aimed to evaluate the correlation between nasal resistance and oxygen desaturation to better elucidate the role of nasal obstruction in the pathophysiology of obstructive sleep apnea (OSA).

Patients And Methods: Eighty-eight OSA patients aged between 22 and 77 years were enrolled in this study. Nasal resistance was measured at pressures of 75, 150, and 300 Pa, with the patients first in the seated position than in the supine position. Relationships between the oximetric variables and nasal resistance in the seated and supine positions were analyzed.

Results: From seated to supine position, a statistically significant increase in nasal resistance was observed at pressures of 75 and 150 Pa (p=0.001 and p=0.006, respectively). Significant positive correlations were noted between nasal resistance in the supine position at 75 Pa (SupineNR75) and oximetry variables, including oxygen desaturation index (ODI, p=0.015) and the percentage of total time with oxygen saturation level lower than 90% (T < 90%, p=0.012). However, significant positive correlations existed only in moderate to severe OSA when the study group was further divided into two subgroups (mild vs moderate to severe OSA). Body mass index (β = 0.476, p<0.001) and SupineNR75 (β = 0.303, p=0.004) were identified as independent predictors for increased ODI.

Conclusion: Nasal resistance in the supine position measured at 75 Pa significantly correlated with the severity of oxygen desaturation. Therefore, nasal obstruction may play an important role in the pathophysiology of hypoxemia in OSA patients, especially in patients with moderate to severe OSA.
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http://dx.doi.org/10.2147/NSS.S288618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811484PMC
January 2021

Characteristics and overall survival in pediatric versus adult skull base chordoma: a population-based study.

Childs Nerv Syst 2021 Jun 18;37(6):1901-1908. Epub 2021 Jan 18.

Department of Neurosurgery, University of California, Irvine, CA, USA.

Purpose: Less than 5% of chordomas occur in pediatric patients. While many studies have explored the treatment and outcomes of skull base chordomas, few have focused on the differences between pediatric and adult populations. The aim of this study is to analyze the epidemiological variables and clinical outcomes between pediatric and adult skull base chordomas using a large-sample, population-based cancer database.

Methods: The National Cancer Database was queried between 2004 and 2015 for skull base chordomas. We stratified patients as pediatric (<18 years) and adults (≥18 years). We compared several clinical covariates between the two groups.

Results: Our cohort consisted of 658 patients, 61 pediatric (9.3%), and 597 adults (90.7%). Pediatric patients were more likely to have larger tumor size (41.4 ± 15.7 mm versus 34.1 ± 15.8 mm, p < 0.01) and universally treated at academic facilities. There was no significant difference in overall survival.

Conclusions: Pediatric skull base chordomas are rare tumors that are managed with aggressive surgical resection, followed by radiation. While there may be difference between tumor presentation, outcomes between pediatric and adult patients are similar.
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http://dx.doi.org/10.1007/s00381-021-05046-6DOI Listing
June 2021

Adenocarcinoma of the Sinonasal Tract: A Review of the National Cancer Database.

J Neurol Surg B Skull Base 2020 Dec 12;81(6):701-708. Epub 2019 Sep 12.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.

 Sinonasal adenocarcinoma (SNAC) is a rare malignancy arising from mucus-secreting glandular tissue. Limited large-scale studies are available due to its rarity. We evaluated SNAC in the National Cancer Database (NCDB), a source that affords multi-institutional, population studies of rare cancers and their outcomes.  The NCDB was queried for adenocarcinoma in the sinonasal tract. Multivariate analyses were performed to evaluate for factors contributing to overall survival (OS).  A total of 553 patients were identified. The cohort was composed of 59.3% males. The nasal cavity was the most common primary site, representing 44.1% of cases. About 5.7% of patients presented with nodal disease, while 3.3% had distant metastases. About 40.6% of cases presented with stage IV disease. About 73.5% of patients underwent surgery, 54.2% received radiation therapy, and 27.7% had chemotherapy. Median OS was 71.7 months, while OS at 1, 2, and 5 years was 82, 73.0, and 52%, respectively. On multivariate analysis, advanced age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.02-1.05), Charlson-Deyo score of 1 (HR: 1.99; 95% CI: 1.20-3.30), advanced tumor grade (HR: 2.73; 95% CI: 1.39-5.34), and advanced tumor stage (HR: 2.71; 95% CI: 1.33-5.50) were associated with worse OS, whereas surgery (HR: 0.34; 95% CI: 0.20-0.60) and radiation therapy (HR: 0.55; 95% CI: 0.33-0.91), but not chemotherapy (HR: 1.16; 95% CI: 0.66-2.05), predicted improved OS.  SNAC is a rare malignancy with 5-year survival approximating 50%. Surgery and radiation therapy, but not chemotherapy, are associated with improved survival, and likely play a critical role in the interdisciplinary management of SNAC.
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http://dx.doi.org/10.1055/s-0039-1696707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755511PMC
December 2020

Appropriate extent of surgery for aspirin-exacerbated respiratory disease.

World J Otorhinolaryngol Head Neck Surg 2020 Dec 8;6(4):235-240. Epub 2020 Sep 8.

Department of Otolaryngology- Head and Neck Surgery, University of California, Irvine, USA.

The current literature lacks strong guidelines regarding surgical management of patients with aspirin-exacerbated respiratory disease (AERD), who present with the clinical triad of chronic rhinosinusitis with nasal polyposis (CRSwNP), bronchial asthma, and aspirin/nonsteroidal anti-inflammatory drug intolerance. To further define the effectiveness of sinus surgery in treating AERD patients, this review article discusses current evidence regarding outcomes associated with more extensive surgery, the benefits of frontal sinus surgery on polyposis, and the role of Draf III intervention. Numerous studies suggest that Draf III frontal sinusotomy may be an efficacious early intervention due to increased neo-ostial patency and subsequent distribution of topical therapies. Future studies that further investigate the efficacy and safety of extensive surgery in AERD patients are warranted.
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http://dx.doi.org/10.1016/j.wjorl.2020.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729211PMC
December 2020

Exhalation Delivery Systems for Application of Intranasal Corticosteroids.

Ear Nose Throat J 2020 Dec 11:145561320980194. Epub 2020 Dec 11.

Department of Otolaryngology-Head and Neck Surgery, 8788University of California, Irvine, CA, USA.

Background: Chronic rhinosinusitis (CRS) is a common sinonasal disorder which results in significant inflammation in the nasal cavity and paranasal sinuses. Topical nasal steroids play an important role in the treatment of CRS. Exhalation delivery system with fluticasone (EDS-FLU) utilizes a patient's forced exhalation to power the delivery of topical steroids to deeper areas of the nasal cavity and paranasal sinuses most affected by CRS. This review focuses on evidence surrounding the safety and efficacy of the EDS-FLU system.

Methods: Literature search was conducted of articles investigating the safety and efficacy of EDS-FLU. Relevant efficacy and safety data were examined and summarized from the studies.

Results: The efficacy and safety of EDS-FLU in CRS, both with and without polyps, has been established in open-label and placebo-controlled phase 3 trials. There was significant improvement in the cardinal symptoms of CRS and subjective patient-reported outcomes scores. Additionally, there was objective improvement in sinonasal inflammation as measured by polyp grade. Recent studies have also established significant improvement in health status and general quality of life following treatment using EDS-FLU. Emerging data have also examined patients who have previously had endoscopic sinus surgery and on appropriate medical therapy and noted improvement in polyp burden and overall Lund-Kennedy scores after using EDS-FLU.

Conclusion: Exhalation delivery system with fluticasone demonstrates significant results in both patient-oriented outcomes and objective measures of sinonasal inflammation in patients with CRS with and without polyps. Further research is needed to investigate the long-term outcomes of EDS-FLU and to compare the effects of EDS-FLU with ESS. Exhalation delivery system with fluticasone provides an additional effective treatment modality for patients suffering from CRS.
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http://dx.doi.org/10.1177/0145561320980194DOI Listing
December 2020

Outcomes of Concurrent Functional Endoscopic Sinus Surgery and Rhinoplasty: A Meta-analysis.

Am J Rhinol Allergy 2020 Dec 10:1945892420980673. Epub 2020 Dec 10.

Department of Otolaryngology-Head and Neck Surgery, University of California Irvine Medical Center, Orange, California.

Introduction: Chronic rhinosinusitis (CRS) and functional nasal airway obstruction are common but distinct medical problems which affect quality of life. In certain instances, patients often benefit from concomitant functional septorhinoplasty, or elect for cosmetic rhinoplasty, in addition to functional endoscopic sinus surgery (FESS) and prefer combining procedures. Determining outcomes of combined surgery is important when discussing risks and benefits with patients.

Methods: A thorough literature search of articles published in PubMed, Ovid MEDLINE, and Cochrane databases. Patients were categorized as either having FESS or rhinoplasty alone or combined. Binary random-effects models were applied to calculate odds ratios (ORs) for outcomes including complications, recurrence, and satisfaction.

Results: Of the 55 screened articles, 6 were included in the analysis, and of these, 6 (405 patients), 2 (90 patients), 4 (290 patients), and 3 (190 patients) provided data for postoperative complications, recurrence of CRS symptoms, revision rates, and patient satisfaction, respectively. Major complications were observed in 11 (5.8%) total combined cases, 0 (0%) FESS cases, and 6 (3.5%) rhinoplasty cases with no statistical difference between combined cases and rhinoplasties (OR 1.37, 95% CI 0.45-4.16, p = 0.58). Recurrence of CRS symptoms was noted in 35.6% combined cases and 28.9% FESS cases (OR 1.42, 95% CI 0.55-3.64, p = 0.47). There was no observed difference in revision rates between combined and isolated rhinoplasties (OR 1.00, 95% CI 0.43-2.32, p = 1). Lastly, 91.6% of patients were satisfied with results of combined cases compared to 87.4% of patients in standalone cases (OR 1.57, 95% CI 0.61-4.03, p = 0.35).

Conclusion: Aggregate evidence demonstrates similar risk in complication rates in combined surgical cases compared to stand-alone rhinoplasty. There appears to be no significant difference in recurrence of symptoms, revision rates or patient satisfaction.
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http://dx.doi.org/10.1177/1945892420980673DOI Listing
December 2020

Otolaryngology Residency Programs' Rising Social Media Presence During the COVID-19 Pandemic.

Laryngoscope 2021 05 10;131(5):E1457-E1459. Epub 2020 Dec 10.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, U.S.A.

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http://dx.doi.org/10.1002/lary.29299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753419PMC
May 2021

A Comprehensive Analysis of Treatment Management and Survival Outcomes in Nasopharyngeal Carcinoma.

Otolaryngol Head Neck Surg 2020 Nov 24:194599820973241. Epub 2020 Nov 24.

Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California, USA.

Objectives: To comprehensively investigate nasopharyngeal carcinoma (NPC) treatment, overall survival (OS), and the influence of clinical/sociodemographic factors on outcome.

Study Design: Retrospective database study.

Setting: National Cancer Database.

Methods: The 2004-2015 National Cancer Database was queried for all patients with NPC receiving definitive treatment. Log-rank tests and Cox proportional hazards models were used for statistical analyses.

Results: A total of 8260 patients with NPC were included (71.4% male; 42.5% with keratinizing histology; mean ± SD age, 52.1 ± 15.1 years), with a 5-year OS of 63.4%. Multivariate predictors of mortality included age ≥65 years (hazard ratio [HR], 1.81; < .001), Charlson/Deyo score ≥1 (HR, 1.27; = .001), American Joint Committee on Cancer clinical stage III to IV (HR, 1.85; < .001), and government insurance or no insurance (HR, 1.53; < .001). Predictors of survival included female sex (HR, 0.82; = .002), Asian/Pacific Islander race (HR, 0.74; < .001), nonkeratinizing/undifferentiated histology (HR, 0.79; = .004), and receiving treatment at academic centers (HR, 0.87; = .02). Chemoradiotherapy (CRT) demonstrated improved OS as compared with radiotherapy (RT) only for stage II ( = .006) and stage III ( = .005) and with RT or chemotherapy only in stage IVA NPC ( < .001). When compared with CRT alone, surgery plus CRT provided OS benefits in keratinizing ( = .013) or stage IVA ( = .030) NPC. When compared with RT, CRT provided OS benefits in keratinizing ( = .005) but not nonkeratinizing ( = .240) or undifferentiated ( = .390) NPC. Substandard radiation dosing of <60 Gy and <30 fractions were associated with inferior OS (both < .001).

Conclusions: NPC survival is dependent on a variety of clinical/sociodemographic factors. Stage-specific treatments with optimal OS include CRT or RT for stages I to II and CRT for stage III to IV. The large representation of nonendemic histology is valuable, as these cases are not well characterized.
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http://dx.doi.org/10.1177/0194599820973241DOI Listing
November 2020

Ergonomics of Endoscopic Skull Base Surgery: A Systematic Review.

World Neurosurg 2021 02 12;146:150-155. Epub 2020 Nov 12.

Department of Neurosurgery, University of California, Irvine, Orange, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA. Electronic address:

Objective: There has been a significant expansion in endonasal endoscopic skull base surgery (EES) that has been used to address a wide range of intracranial and sinonasal pathologies. Although there exists a large amount of literature on approaches and patient outcomes, there is a paucity of data describing ergonomics in this field. Our goal was to evaluate and summarize the literature on ergonomics in EES.

Methods: We systematically reviewed all published, peer-reviewed, English language literature in the PubMed and Web of Science databases as screened by multiple reviewers describing ergonomics as related to EES.

Results: A total of 50 articles were found that described significant conclusions and descriptions on ergonomics in EES. We found and summarized the different technical aspects of ergonomics as pertaining to EES and provided evidence-based suggestions on operating room and surgeon setup.

Conclusions: There are several improvements in EES ergonomics that can decrease fatigue, improve efficiency, and overall surgeon well-being.
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http://dx.doi.org/10.1016/j.wneu.2020.11.026DOI Listing
February 2021

Spontaneous Involution of Juvenile Nasopharyngeal Angiofibromas: Report of a Case.

Laryngoscope 2021 07 11;131(7):1455-1457. Epub 2020 Nov 11.

Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A.

Juvenile nasopharyngeal angiofibroma (JNA) is a locally aggressive tumor that predominantly affects adolescent males. Surgical resection is generally considered the standard treatment for both primary and recurrent tumors, regardless of staging. The natural history of these tumors, particularly when untreated or in the setting of residual tumor, is not well characterized. In this article, we report a case of true spontaneous JNA involution. Although the involution of residual tumor after surgical resection has previously been reported, to our knowledge, this is the first documented case of spontaneous JNA involution following a period of tumor growth post-treatment. Laryngoscope, 131:1455-1457, 2021.
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http://dx.doi.org/10.1002/lary.29246DOI Listing
July 2021

Disorders Involving a Persistent Craniopharyngeal Canal: A Case Series.

J Neurol Surg B Skull Base 2020 Oct 21;81(5):562-566. Epub 2019 Jun 21.

Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.

 A persistent craniopharyngeal canal (CPC) is a rare embryologic remnant that presents as a well-corticated defect of the midline sphenoid body extending from the sellar floor to the nasopharynx. Our case series aims to describe three unique presentations of this congenital anomaly and their subsequent management.  Retrospective review.  Tertiary academic medical center.  Patients who underwent endoscopic transnasal surgical repair of a CPC lesion.  Resolution of symptoms and surgical outcomes.  A total of three patients were identified. The clinical presentation varied, however, all cases prompted further imaging which demonstrated a persistent CPC and associated pathologic lesion. The presentation of a persistent CPC with nasal obstruction and subsequent iatrogenic cerebrospinal fluid leak as in Case 1 demonstrates the importance of imaging in this work-up. Cases 2 and 3 in the series were representative of the larger subset of patients in the literature who present with the defect incidentally but still warrant surgical management. Nonetheless, a standard approach to diagnosis with preoperative imaging and subsequent transnasal endoscopic repair of the skull base defect was undertaken.  The persistent CPC is a rare congenital anomaly associated with diverse pathology and careful review of preoperative radiology is critical to the management. When warranted, subsequent surgical repair and reconstruction is associated with excellent postoperative outcomes.
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http://dx.doi.org/10.1055/s-0039-1692638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591367PMC
October 2020

Short-Term Morbidity and Predictors of Adverse Events Following Esthesioneuroblastoma Surgery.

Am J Rhinol Allergy 2020 Oct 29:1945892420970468. Epub 2020 Oct 29.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California.

Introduction: The short-term adverse events and predictors of morbidity in surgical resection of esthesioneuroblastoma (ENB) are largely unknown, and investigating these variables can help direct planning for at-risk patients.

Methods: The 2005-2017 National Surgical Quality Improvement Program database was queried to identify patients with a diagnosis of ENB undergoing skull base surgery for tumor resection. Information regarding demographics, patient morbidity score, pre-operative and intra-operative data, and post-operative outcomes were extracted. Cox proportional hazard analysis was utilized to assess complication and readmission/reoperation rates.

Results: A total of 95 patients undergoing skull base surgery for resection of ENB were included. Mean age, BMI, operation time, and post-operative length of stay (LOS) of the cohort were 53.6 ± 16.2 years, 29.1 ± 6.5, 392.0 ± 204.6 minutes, and 5.8 ± 4.6 days, respectively. In total, 31 patients (32.6%) experienced at least one 30-day adverse event, which included blood transfusion intra-operatively or within 72 hours from the operation (22.1%), readmission (10.7%), intubation >48 hours (7.4%), reintubation (4.2%), organ or space infection (4.2%), reoperation (4.0%), superficial or deep surgical site infection (2.1%), sepsis (2.1%), pulmonary embolism (1.1%), and myocardial infarction (1.1%). Patients who experienced at least one adverse event had significantly higher operation time (486.8 ± 230.4 vs. 347.5 ± 176.2 minutes,  = 0.002), LOS (9.2 ± 5.6 days vs. 4.2 ± 3.0,  < 0.001), and lower hematocrit (37.3 ± 5.9 vs. 41.2 ± 3.8,  < 0.001) and albumin levels (3.8 ± 0.6 vs. 4.2 ± 0.3,  = 0.009). Patients with a higher American Society of Anesthesiologists (ASA) score (HR = 2.39;  = 0.047) or longer operation time (HR = 1.004;  = 0.001) had a significantly higher risk for experiencing adverse events. Obesity was not associated with different intra- or post-operative outcomes, but older patients had shorter operations ( = 0.002) and LOS ( = 0.0014).

Conclusion: Longer operation time and lower pre-operative hematocrit and albumin levels may all increase complication rates in ENB resection. Patients with high ASA score or more advanced age may have different short-term outcomes.
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http://dx.doi.org/10.1177/1945892420970468DOI Listing
October 2020

Safety of laser-generated shockwave treatment for bacterial biofilms in a cutaneous rodent model.

Lasers Med Sci 2020 Oct 27. Epub 2020 Oct 27.

Department of Head and Neck Surgery, UCLA Medical Center, Los Angeles, CA, USA.

Bacterial biofilms are often found in chronically infected wounds. Biofilms protect bacteria from antibiotics and impair wound healing. Surgical debridement is often needed to remove the biofilm from an infected wound. Laser-generated shockwave (LGS) treatment is a novel tissue-sparing treatment for biofilm disruption. Previous studies have demonstrated that LGS is effective in disrupting biofilms in vitro. In this study, we aim to determine the safety threshold of the LGS technology in an in vivo rodent model. To understand the in vivo effects of LGS on healthy cutaneous tissue, the de-haired dorsal skin of Sprague-Dawley rats were treated with LGS at three different peak pressures (118, 296, 227 MPa). These pressures were generated using a 1064 nm Nd/YAG laser (pulse duration 5 ns and laser fluence of 777.9 mJ) with laser spot size diameters of 2.2, 3.0, and 4.2 mm, respectively. Following treatment, the animals were observed for 72 h, and a small subset was euthanized at 1-h, 24-h, and 72-h post-treatment and assessed for tissue injury or inflammation under histology. Each treatment group consisted of 9 rats (n = 3/time point for 1-h, 24-h, 72-h post-treatment). An additional 4 control (untreated) rats were included in the analysis, for a total of 31 animals. Gross injuries occurred in 21 (77%) animals and consisted of minor erythema, with prevalence positively correlated with peak pressure (p < 0.05). Of injuries under gross observation, 94% resolved within 24 h. Under histological analysis, the injuries and tissue inflammation were found to be localized to the epidermis and superficial dermis. LGS appears to be well tolerated by cutaneous tissue for the laser energy settings shown to be effective against bacterial biofilm in vitro. All injuries incurred, at even the highest peak pressures, were clinically mild and resolved within 1 day. This lends further support to the overall safety of LGS and serves to translate LGS towards in vivo efficacy studies.
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http://dx.doi.org/10.1007/s10103-020-03171-3DOI Listing
October 2020

Assessing the Safety of Topical Epinephrine in Open Rhinoplasty.

Facial Plast Surg Aesthet Med 2021 Jan-Feb;23(1):73-74. Epub 2020 Oct 22.

Beckman Laser Institute and Medical Clinic, University of California-Irvine, Irvine, California, USA.

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http://dx.doi.org/10.1089/fpsam.2020.0362DOI Listing
October 2020

Treatment modalities and overall survival outcomes for sinonasal extranodal natural killer/T-cell lymphoma.

Leuk Lymphoma 2021 03 15;62(3):727-730. Epub 2020 Oct 15.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA.

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http://dx.doi.org/10.1080/10428194.2020.1834097DOI Listing
March 2021

Extraprimary Local Recurrence of Esthesioneuroblastoma: Case Series and Literature Review.

World Neurosurg 2020 12 8;144:e546-e552. Epub 2020 Sep 8.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA; Department of Neurological Surgery, University of California, Irvine Medical Center, Orange, California, USA. Electronic address:

Objectives: Esthesioneuroblastoma (ENB) is a rare sinonasal malignancy arising from olfactory neuroepithelium. Recurrence typically occurs locoregionally at the primary site or in the form of cervical metastasis. Delayed local recurrence away from the initial primary site is exceedingly rare.

Methods: Retrospective review of 4 patients with histologically confirmed extraprimary local recurrence of ENB was performed with review of the literature.

Results: All cases initially presented with ENB isolated to the cribriform plate(s) treated with primary surgical resection and adjuvant radiotherapy. The first patient had ENB recurrence 8 years posttreatment involving the right orbit. She later developed metastases to the spine, neck, and mandible requiring composite resection and 4 courses of radiotherapy. The second patient had ENB recurrence of the dorsal septum 9 years posttreatment with cervical metastases requiring septectomy, bilateral neck dissection, and radiotherapy. The third patient had ENB recurrence 7 years posttreatment in the posterior nasopharynx requiring endonasal nasopharyngectomy. Finally, the fourth patient had ENB recurrence 12 years posttreatment in the sphenopalatine foramen, which was endoscopically resected. At the time of this review, all 4 patients were disease free at 32, 21, 4, and 24 months posttreatment follow-ups, respectively.

Conclusions: This case series describes the rare phenomenon of delayed extraprimary local recurrence of histologically confirmed ENB. Treatment of extraprimary recurrences, analogous to other forms of ENB, should include primary surgical resection with adjuvant radiotherapy for generally favorable outcomes. Long-term close follow-up based on symptoms, endoscopy, and imaging is essential because of the risk of delayed recurrence.
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http://dx.doi.org/10.1016/j.wneu.2020.08.227DOI Listing
December 2020