Publications by authors named "Evan Walgama"

31 Publications

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

Head Neck 2021 May 11. Epub 2021 May 11.

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

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

Nodal staging convergence for HPV- and HPV+ oropharyngeal carcinoma.

Cancer 2021 May 17;127(10):1590-1597. Epub 2021 Feb 17.

Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California.

Background: Modern disease staging systems have restructured human papillomavirus (HPV)-negative (HPV-) and HPV-positive (HPV+) oropharyngeal carcinoma (OPC) into distinct pathologic nodal systems. Given that quantitative lymph node (LN) burden is the dominant prognostic factor in most head and neck cancers, we investigated whether HPV- and HPV+ OPC warrant divergent pathologic nodal classification.

Methods: Multivariable Cox regression models of OPC surgical patients identified via U.S. cancer registry data were constructed to determine associations between survival and nodal characteristics. Nonlinear associations between metastatic LN number and survival were modeled with restricted cubic splines. Recursive partitioning analysis (RPA) was used to derive unbiased nodal schema.

Results: Mortality risk escalated continuously with each successive positive LN in both OPC subtypes, with analogous slope. Survival hazard increased by 18.5% (hazard ratio [HR], 1.19 [95% CI, 1.16-1.21]; P < .001) and 19.1% (HR, 1.19 [95% CI, 1.17-1.21]; P < .001), with each added positive LN for HPV- and HPV+ OPC, respectively, up to identical change points of 5 positive LNs. Extranodal extension (ENE) was an independent predictor of HPV- OPC (HR, 1.55 [95% CI, 1.20-1.99]; P < .001) and HPV+ OPC (HR 1.73 [95% CI, 1.36-2.20]; P < .001) mortality. In RPA for both diseases, metastatic LN was the principal nodal covariate driving survival, with ENE as a secondary determinant. Given the similarities across analyses, we propose a concise, unifying HPV-/HPV+ OPC pathologic nodal classification schema: N1, 1-5 LN+/ENE-; N2, 1-5 LN+/ENE+; N3, >5 LN+.

Conclusion: HPV- and HPV+ OPC exhibit parallel relationships between nodal characteristics and relative mortality. In both diseases, metastatic LN number represents the principal nodal covariate governing survival, with ENE being an influential secondary element. A consolidated OPC pathologic nodal staging system that is based on these covariates may best convey prognosis.

Lay Summary: The current nodal staging system for oropharyngeal carcinoma (OPC) has divided human papillomavirus (HPV)-negative (HPV-) and HPV-positive (HPV+) OPC into distinct systems that rely upon criteria that establish them as separate entities, a complexity that may undermine the core objective of staging schema to clearly communicate prognosis. Our large-scale analysis revealed that HPV- and HPV+ pathologic nodal staging systems in fact mirror each other. Multiple analyses produced conspicuously similar nodal staging systems, with metastatic lymph node number and extranodal extension delineating the highest risk groups that shape prognosis. We propose unifying HPV- and HPV+ nodal systems to best streamline prognostication and maximize staging accuracy.
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http://dx.doi.org/10.1002/cncr.33414DOI Listing
May 2021

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

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

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

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

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

Setting: Patients with nonabsorbable nasal packing placed.

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

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

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

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

Effect of nasal fluticasone exhalation delivery system on Eustachian tube dysfunction.

Int Forum Allergy Rhinol 2021 Feb 2;11(2):204-206. Epub 2020 Nov 2.

Department of Otolaryngology, University of Louisville, Louisville, KY.

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http://dx.doi.org/10.1002/alr.22728DOI Listing
February 2021

Infectious Complications of Expanded Endoscopic Transsphenoidal Surgery: A Retrospective Cohort Analysis of 100 Cases.

J Neurol Surg B Skull Base 2020 Oct 4;81(5):497-504. Epub 2019 Sep 4.

Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States.

 To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS).  This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis.  A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33-56.47;  = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected.  CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.
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http://dx.doi.org/10.1055/s-0039-1696999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591357PMC
October 2020

Patient satisfaction survey experience among American otolaryngologists.

Am J Otolaryngol 2020 Nov - Dec;41(6):102656. Epub 2020 Aug 5.

Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America. Electronic address:

Background: Patient Satisfaction (PS) is a commonly used metric in health care settings to assess the quality of care given by physicians. Monitoring physicians in this way may impact physician quality of life. Studies evaluating this impact are not available. This study sought to examine the physician experience of measuring PS among practicing otolaryngologists.

Methods: Using an online survey platform, a 34-item survey was given to practicing otolaryngologists through email distribution. The survey included questions about physician, practice and patient demographics, as well as inquiries regarding the way in which PS was measured and how it affected physician work and personal life. Data from these questions were reviewed and analyzed.

Results: 174 otolaryngologists responded to the survey. A majority of physicians' (55.3%) PS scores had been tracked with 89.9% reporting being tracked for a length of at least 1 year. PS scores for individual physicians were noted to be inconsistent and vary significantly between reports. Measuring patient satisfaction led to increased occupational stress, yet most physicians (63.8%) felt the monitoring did not lead to improvements in their practice. Some physicians (36.2%) reported that the collection of patient satisfaction scores had negatively influenced the way they practiced medicine, including the pressure to order superfluous tests or to prescribe unnecessary medications.

Conclusion: Overall, physicians are negatively affected by the tracking of patient satisfaction scores. Occupational stress caused by the collection of patient satisfaction scores may contribute to physician burnout.
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http://dx.doi.org/10.1016/j.amjoto.2020.102656DOI Listing
December 2020

Prognostic Impact of Histologic Grade for Papillary Thyroid Carcinoma.

Ann Surg Oncol 2021 Mar 17;28(3):1731-1739. Epub 2020 Aug 17.

Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Background: While numerous factors affect prognosis in papillary thyroid carcinoma (PTC), the comparative impact of histologic grade has not been well described. Moreover, indications for external beam radiation therapy (EBRT) remain imprecise. We evaluate clinicopathologic characteristics and outcomes for PTC stratified by grade.

Methods: We profiled histologic grade for PTC (well differentiated, moderately differentiated, poorly differentiated) via hospital (National Cancer Database) and population-based (Surveillance, Epidemiology, and End Results) registries. Cox regression was used to adjust for clinicopathologic covariates. Statistical interactions between subtypes and the effect of EBRT on survival were assessed.

Results: Collectively, worsening clinicopathologic factors (age, tumor size, extrathyroidal extension, nodal spread, M1 disease) and outcomes (disease-free survival, overall survival) correlated with less differentiated state, across all histologic grades (p < 0.001). Multivariable analysis showed escalating hazard with loss of differentiation relative to well-differentiated PTC (moderately differentiated hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.04-1.41, p = 0.02; poorly differentiated HR 2.62, 95% CI 2.23-3.08, p < 0.001). Correspondingly, greater survival benefit was associated with EBRT for poorly differentiated cases (HR 0.36, 95% CI 0.18-0.72, p = 0.004). This finding was upheld after landmark analysis to address potential immortal time bias (HR 0.37, 95% CI 0.17-0.80, p = 0.01).

Conclusions: Worsening histologic grade in PTC is independently associated with parallel escalation in mortality risk, on a scale approximating or surpassing established thyroid cancer risk factors. On preliminary analysis, EBRT was associated with improved survival in the most aggressive or least differentiated subvariants. Further investigation is warranted to examine the efficacy of EBRT for select poorly differentiated thyroid carcinomas.
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http://dx.doi.org/10.1245/s10434-020-09023-2DOI Listing
March 2021

Cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for low-risk thyroid cancer patients.

Head Neck 2020 09 8;42(9):2593-2601. Epub 2020 Jun 8.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Background: Flexible fiberoptic laryngoscopy is performed prior to thyroid surgery to evaluate the function of the recurrent laryngeal nerve. We assess the cost-effectiveness of preoperative laryngoscopy prior to total thyroidectomy for a low-risk thyroid cancer patient without dysphonia.

Methods: A decision tree analysis was performed from a third-party payer perspective. We assessed the cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for T2N0M0 papillary thyroid carcinoma, such that an ipsilateral vocal fold paralysis alters the surgical plan to hemi-thyroidectomy, when permissible, to avoid the risk of bilateral vocal fold paralysis.

Results: Performing preoperative laryngoscopy to assess vocal fold function has an incremental cost-effectiveness ratio (ICER) of 45 193 USD/QALY compared to no laryngoscopy. At a willingness-to-pay of 100 K/QALY, the intervention is cost-effective if the incidence of vocal fold paralysis is at least 0.57%, or when the permissible rate of hemithyroidectomy in cases of incidental paralysis is at least 41%. Probabilistic sensitivity analysis shows that laryngoscopy is cost-effective in 90.9% of cases.

Conclusions: Fiberoptic laryngoscopy is a cost-effective prior to total thyroidectomy in asymptomatic, low-risk thyroid cancer patients.
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http://dx.doi.org/10.1002/hed.26312DOI Listing
September 2020

Voice-Related Quality of Life in Patients with Chronic Rhinosinusitis.

Ann Otol Rhinol Laryngol 2020 Oct 26;129(10):983-987. Epub 2020 May 26.

Cedars-Sinai Division of Otolaryngology-Head & Neck Surgery, Los Angeles, CA, USA.

Objective: Chronic rhinosinusitis (CRS) has long been associated with vocal dysfunction. However, studies quantifying the presence of voice dysfunction in CRS patients or the effects of functional endoscopic sinus surgery (FESS) are sparse. The goal of this study was to determine the voice-related quality of life in patients undergoing FESS for CRS using the validated Voice Related Quality of Life Survey (VRQL). We correlated the preoperative VRQL scores to the Sino-Nasal Outcome Test (SNOT-22) scores, and we determined the effect of FESS on postoperative VRQL scores.

Methods: Consecutive patients undergoing FESS were preoperatively administered both the VRQL and the SNOT-22 surveys. Spearman (ρ) and Pearson () correlation coefficients were calculated. The VRQL was mailed to patients postoperatively between 3 and 6 months. The paired t-test was used to compare pre- and post-FESS scores.

Results: A total of 102 patients were enrolled, and 81 patients completed the two surveys. A total of 51 (62.9%) patients had raw VRQL score ≥ 10, signifying presence of significant vocal symptoms. The mean ± standard deviation (SD) raw VRQL score of the entire study population was 12.4 ± 4.6, and the mean SNOT-22 score was 37.8 ± 19.2. The Spearman correlation coefficient between VRQL and the total SNOT-22 score was 0.34 ( =.002), and the Pearson correlation coefficient was 0.36 ( = .001). Both correlations were similar, demonstrating that increasing severity of CRS symptoms correlates with decreasing voice-related quality of life (QOL). Seventy patients completed the postoperative survey for an 86% retention rate. Thirty-six of these patients had abnormal preoperative VRQL scores, and these patients improved significantly after FESS. The mean preoperative versus postoperative raw scores were 15.2 ± 5.6 versus 12.5 ± 4.1, respectively ( = .003).

Conclusion: This study demonstrates the increasing presence of vocal complaints with increasing severity of CRS. It also demonstrates that VRQL scores improve after FESS in those patients with preoperative vocal complaints.

Level Of Evidence: IV.
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http://dx.doi.org/10.1177/0003489420924061DOI Listing
October 2020

Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps.

Laryngoscope 2021 01 3;131(1):E26-E33. Epub 2020 Apr 3.

Department of Otolaryngology, University of Louisville School of Medicine, Louisville, Kentucky, U.S.A.

Objective: Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP.

Study Design: Cohort-style Markov decision-tree economic model with a 36-year time horizon.

Methods: A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed.

Results: The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855.

Conclusions: The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner.

Level Of Evidence: 2C Laryngoscope, 131:E26-E33, 2021.
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http://dx.doi.org/10.1002/lary.28648DOI Listing
January 2021

Eustachian Tube Quality of Life and Severity of Disease in Patients With Chronic Rhinosinusitis.

Am J Rhinol Allergy 2020 Jul 18;34(4):532-536. Epub 2020 Mar 18.

Division of Otolaryngology-Head & Neck Surgery, Cedars-Sinai Sinus Center, Los Angeles, California.

Background: Chronic rhinosinusitis (CRS) has long been a suspected risk factor for Eustachian tube dysfunction (ETD). However, there have been few studies quantifying the presence of ETD in CRS patients. We sought to determine the prevalence of ETD symptoms in patients undergoing functional endoscopic sinus surgery (FESS) for CRS using the validated 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and to correlate the ETDQ-7 scores with scores of CRS symptom severity based on the 22-item Sino-Nasal Outcome Test (SNOT-22).

Methods: Patients for FESS were preoperatively administered both the ETDQ-7 and the SNOT-22 validated quality of life instruments. Pearson and Spearman correlation coefficients were calculated. Changes in ETDQ-7 were measured at 3 months and differences were compared via paired test.

Results: A total of 82 patients completed the surveys. Thirty-nine (47.6%) patients had ETDQ-7 score ≥14.5, signifying clinically significant ETD symptoms. The mean ETDQ-7 score of the study population was 15.8 ± 8.8, and the mean SNOT-22 score was 37.5 ± 19.7. The Pearson and Spearman correlation coefficients between ETDQ-7 and the total SNOT-22 score were 0.52 ( > .0001) and 0.51 ( < .0001), respectively. There was significant improvement in ETDQ-7 scores postoperatively.

Conclusion: While the association between ETD and CRS has long been known, this is one of the few prospective patient studies evaluating otologic symptoms in a CRS population. We found that a significant percentage of CRS patients suffer from ETD symptoms based on patient-reported subjective outcome measures. This study demonstrates that otologic symptoms increase with CRS severity and improve after FESS.
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http://dx.doi.org/10.1177/1945892420912366DOI Listing
July 2020

Multicenter study on the effect of nonsteroidal anti-inflammatory drugs on postoperative pain after endoscopic sinus and nasal surgery.

Int Forum Allergy Rhinol 2020 04 13;10(4):489-495. Epub 2019 Dec 13.

Rhinology, Sinus & Skull Base, Kentuckiana Ear, Nose, & Throat, Department of Otolaryngology-Head & Neck Surgery, University of Louisville, Louisville, KY.

Background: The taboo of avoiding nonsteroidal anti-inflammatory drugs (NSAIDs) after functional endoscopic sinus surgery (FESS) has been waning. The impetus to reduce opioid prescriptions in view of the opioid epidemic led the authors to change their practices to include NSAIDs after sinus surgery. This study's aim was to analyze the differences between patients before and after we began recommending NSAIDs after FESS.

Methods: A prospective cohort study was performed on patients undergoing FESS or other endoscopic nasal surgeries at 3 institutions, by 5 rhinologists and 1 facial plastic surgeon. Before introducing NSAIDs, all patients were given a prescription for hydrocodone-acetaminophen 5/325 mg and also recommended preferentially to use acetaminophen 325 mg. After the addition of NSAIDs, ibuprofen 200 mg and acetaminophen 325 mg were recommended preferentially, using the narcotic as a rescue medication. Patients kept a pain diary and medication log, and gave a visual analog scale (VAS) score for overall pain. Demographics, surgical variables, and comorbidities were also analyzed.

Results: One hundred sixty-six total patients were recruited and had data that could be analyzed (65 without NSAIDs, 101 with NSAIDs). Overall, mean pain VAS score was 3.12 ± 1.95 for the non-NSAID group and 2.33 ± 2.30 for the NSAID group (p value = 0.006). The day with the highest mean pain was the first postoperative day. The mean number of total opioid pills taken was 6.94 ± 6.85 without NSAIDs vs 3.77 ± 4.56 with NSAIDs (p = 0.018). Age and gender were found to be the only consistently significant patient variables to affect pain. There were no bleeding complications.

Conclusion: NSAID use was introduced into the practices of 5 practicing rhinologists and 1 facial plastic surgeon. No bleeding complications were seen. Both pain and overall opioid usage were reduced significantly.
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http://dx.doi.org/10.1002/alr.22506DOI Listing
April 2020

Papillary thyroid microcarcinoma: optimal management versus overtreatment.

Curr Opin Oncol 2020 01;32(1):1-6

Department of Surgery, Division of Otolaryngology - Head and Neck Surgery.

Purpose Of Review: The treatment of small, low-risk papillary thyroid carcinoma has undergone a paradigm shift, with many tumors now initially treated with active surveillance rather than upfront surgery. Further studies on patients enrolled in active surveillance have refined our knowledge of the clinical behavior of papillary thyroid microcarcinomas.

Recent Findings: This article summarizes the major conclusions of landmark trials that launched active surveillance as a viable treatment option for selected patients. We discuss patient factors such as age and tumor size, the assessment of candidates for active surveillance, barriers to acceptance of active surveillance, quality of life issues, and economic considerations.

Summary: Active Surveillance is a viable first-line treatment option for select papillary microcarcinomas.
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http://dx.doi.org/10.1097/CCO.0000000000000595DOI Listing
January 2020

The prevalence of eustachian tube dysfunction symptoms in temporomandibular joint disorder patients.

Laryngoscope 2020 04 2;130(4):E233-E236. Epub 2019 Jul 2.

Division of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A.

Objectives/hypothesis: Ear fullness and pressure is a common complaint seen in otolaryngology clinics and frequently is attributed to eustachian tube dysfunction (ETD). In addition to traditional tympanometry and physical examination, the seven-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) has recently been used to aid in the diagnosis of ETD and to assess its severity. Temporomandibular joint disorder (TMJD) is a common condition that causes similar symptoms to ETD and has been recognized as a potential confounding condition in patients presenting with ETD symptoms. We sought to determine the cross-sectional prevalence of ETD symptoms in patients with TMJD using the ETDQ-7.

Study Design: Prospective cross-sectional analysis.

Methods: An analysis was performed of ETDQ-7 scores in patients diagnosed with TMJD.

Results: A total of 21 patients with confirmed TMJD completed the ETDQ-7 at routine consult or follow-up for their TMJD. The mean ± standard deviation ETDQ-7 score for the cohort was 24.5 ± 12.5. Two-thirds of patients had an ETDQ-7 score of >14.5, which has been used in the literature to denote clinically significant ETD. No single question was scored significantly higher than the others.

Conclusions: Symptoms of ETD are highly prevalent among patients with TMJD determined by patient-reported outcome measures. It is not clear if these symptoms reflect true derangement of eustachian tube function in these patients or whether there is only clinical similarity between ETD and TMJD. However, future research efforts may resolve this dilemma.

Level Of Evidence: 4 Laryngoscope, 130:E233-E236, 2020.
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http://dx.doi.org/10.1002/lary.28162DOI Listing
April 2020

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

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

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

Confirming a thorough dissection of the frontal sinus during endoscopic sinus surgery can be challenging, and some surgeons would benefit from reliable topographic landmark identification to ensure completion of this sinus dissection. We defined (1) the "horizon sign" as the curvilinear shadow of the posterior table cast superiorly upon the anterior table of the frontal sinus at the acute angle of their meeting point and (2) the "frontal bar" as a sagittal septation at the union of the anterior/posterior tables. A cadaveric study, followed by an intraoperative consecutive case series, was performed to evaluate these 2 landmarks as indicators of complete dissection. The horizon sign was extremely reliable, identified in 100% of cadaveric frontal sinuses and intraoperative frontal sinuses. The frontal bar was present in only 67% of frontal sinuses by computed tomography. In live patients, the sensitivity and specificity of the frontal bar were 62% and 95%, respectively.
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http://dx.doi.org/10.1177/0194599818825472DOI Listing
April 2019

Survey of endoscopic skull base surgery practice patterns among otolaryngologists.

Laryngoscope Investig Otolaryngol 2018 Jun 16;3(3):143-155. Epub 2018 Apr 16.

Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A.

Background: Endoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences.

Methods: An anonymous 32-item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi-square, and Fisher exact tests.

Results: Seventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full-time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice,  = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice ( = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high-flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs ( < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2-8 weeks and positive airway pressure use for 2-6 weeks. Most respondents started saline irrigations 0-2 weeks postoperatively.

Conclusions: Based on responses from fellowship- and non-fellowship-trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS.

Level Of Evidence: 5.
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http://dx.doi.org/10.1002/lio2.149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057222PMC
June 2018

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

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

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

Background: To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing.

Methods: In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases.

Results: Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion.

Conclusion: This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.
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http://dx.doi.org/10.1002/alr.22156DOI Listing
October 2018

Biocompatibility and pharmacokinetics of fluticasone-eluting sinus implant in a rabbit model.

Am J Rhinol Allergy 2017 Nov;31(6):382-388

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

Background: A novel, bioabsorbable, fibrinogen-based implant has been developed as a mucosal dressing after endoscopic sinus surgery (ESS). This implant can be formulated with fluticasone propionate (FP) for local elution of corticosteroid to reduce postoperative inflammation and promote mucosal healing.

Objective: This study investigated the biocompatibility and pharmacokinetics of the implant in a rabbit model.

Methods: Implants with and without FP were placed on both intact and demucosalized maxillary sinuses of 33 New Zealand White rabbits. Sinuses with either intact or denuded bone without implants acted as controls. Histopathologic assessments were carried out at 5, 15, and 28 days. Concentrations of FP in the maxillary sinus mucosa, nasal cavity mucosa, and plasma were measured for up to 44 days.

Results: Implants placed on intact mucosa or denuded bone were grossly integrated within 15 days. Minimal foreign body reaction was seen with negligible differences for inflammation, fibrosis, or bone remodeling among controls, sinuses with the implant, or sinuses with the implant plus FP, at all time points. All samples also showed complete or near-complete percentage reepithelialization at 28 days, although the denuded bone controls demonstrated greater percentage reepithelialization at 5 days compared with denuded bone with the implant or implant plus FP (p < 0.0001). The maxillary sinus mucosa demonstrated levels of FP of >140 ng/g up to 44 days. Plasma concentrations of FP were generally very low and were undetectable after day 7.

Conclusions: The implant and the implant plus FP seemed to be biocompatible in rabbits. The implant plus FP effectively eluted steroid locally over at least 44 days, with negligible plasma concentrations. Further studies are warranted regarding potential therapeutic applications in patients undergoing ESS for chronic rhinosinusitis.
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http://dx.doi.org/10.2500/ajra.2017.31.4481DOI Listing
November 2017

Pediatric sinonasal desmoid tumor.

Ear Nose Throat J 2017 Oct-Nov;96(10-11):417-418

Department of Otolaryngology-Head and Neck Surgery and Comprehensive Skull Base Program, University of Texas Southwestern Medical Center, Dallas, TX, USA.

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http://dx.doi.org/10.1177/0145561317096010-1120DOI Listing
November 2018

Efficacy of endoscopic sinus surgery for chronic rhinosinusitis following primary radiotherapy and concurrent chemotherapy for nasopharyngeal carcinoma.

Int Forum Allergy Rhinol 2017 11 14;7(11):1045-1051. Epub 2017 Aug 14.

Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA.

Background: Chronic rhinosinusitis (CRS) is a downstream complication following radiotherapy or chemoradiation for nasopharyngeal carcinoma (NPC). Endoscopic sinus surgery (ESS) is an accepted therapy for medically refractory CRS, but its efficacy in addressing CRS symptoms in patients with previously irradiated NPC is unclear.

Methods: All patients at the Stanford Sinus Center with a history of radiation therapy or chemoradiation for NPC between 2006 and 2015 were reviewed. Patients without antecedent CRS prior to NPC treatment (n = 26) were retrospectively divided into 2 cohorts based on whether they developed postirradiation CRS and underwent ESS (surgical group, n = 13) or did not develop CRS (control, n = 13). Demographic and clinical characteristics were collected, and temporal changes in 22-item Sino-Nasal Outcome Test (SNOT-22) score were compared.

Results: The median time following primary irradiation to initial presentation was 6.8 and 6.5 years in the surgical and control groups, respectively. The surgical cohort had statistically greater baseline SNOT-22 scores than the control group (45 vs 14, p = 0.0198). At 6 to 12 months postoperatively, the surgical group demonstrated statistically significant and clinically meaningful improvements in SNOT-22 scores when compared to controls (15-point decrease vs 0, p = 0.0040), ultimately resulting in similar SNOT-22 scores for both groups (28 vs 18, p = 0.3687). The rhinologic, extranasal, and ear/face subdomain scores of the surgical group were significantly greater than those of the control group preoperatively (rhinologic: p = 0.0010; extranasal: p = 0.0179; ear/face: p = 0.0068), but these disparities resolved postoperatively (rhinologic: p = 0.1461; extranasal: p = 0.3131; ear/face: p = 0.3401).

Conclusion: ESS appears to effectively manage recalcitrant CRS symptoms in patients previously treated with radiation therapy and concurrent chemotherapy for NPC.
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http://dx.doi.org/10.1002/alr.22002DOI Listing
November 2017

Radioanatomic Study of the Greater Palatine Canal Relevant to Endoscopic Endonasal Surgical Landmarks.

Otolaryngol Head Neck Surg 2017 10 13;157(4):731-736. Epub 2017 Jun 13.

2 Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA.

Objective A radioanatomic study of surgically relevant variations in the greater palatine canal (GPC) on computed tomography (CT) was performed to determine susceptibility during endoscopic endonasal procedures. Study Design Blinded radioanatomic analysis. Setting Tertiary university hospital. Subjects and Methods Fifty consecutive paranasal CT scans (100 sides) were analyzed. Measurements were standardized to landmarks such as the inferior turbinate (IT) and floor of the nasal cavity (FNC) to assess variability and vulnerability of the nerve. Measurements included (1) incidence of maxillary sinus pneumatization posterior to the GPC, (2) distance from the posterior wall of the maxillary sinus to the GPC at the IT and FNC, (3) width of bone containing the GPC, (4) incidence of medial GPC dehiscence, and (5) angle of the GPC extending from the IT to FNC. Results Ninety-one percent of maxillary sinuses were pneumatized posterior to the GPC. The distance from the posterior wall of the maxillary sinus to the GPC was 2.8 ± 1.7 mm (range, -2.3 to 5.9) at the posterior attachment of the IT and 4.1 ± 3.1 mm (range, -6.3 to 11.9) at the FNC. The width of bone containing the GPC was 3.3 ± 1.3 mm (range, 1-8.9), and the medial bony GPC was dehiscent in 38% of cases. In the sagittal plane, the angle of the GPC between the IT and the FNC was 31.9 ± 6.9 degrees (range, 10.8-45). Conclusion The GPC has considerable anatomic variability relative to important surgical landmarks in endoscopic procedures. Preoperative review of CTs to assess vulnerability may prevent postoperative complications.
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http://dx.doi.org/10.1177/0194599817711883DOI Listing
October 2017

Aspirin-Exacerbated Respiratory Disease.

Otolaryngol Clin North Am 2017 Feb;50(1):83-94

Department of Otolaryngology/Head and Neck Surgery, Stanford School of Medicine, Stanford Sinus Center, 801 Welch Road, Palo Alto, CA 94304, USA. Electronic address:

Aspirin-exacerbated respiratory disease (AERD) is characterized by the triad of asthma, sinonasal polyposis, and aspirin intolerance. The hallmark of the disease is baseline overproduction of cysteinyl leukotrienes via the 5-lipoxygenase pathway, exacerbated by ingestion of aspirin. Patients with AERD have high rates of recidivistic polyposis following sinus surgery, although the improvement in quality of life following surgery is similar to aspirin-tolerant patients. The diagnosis is secured by a positive aspirin provocation test, usually administered by a medical allergist. Aspirin therapy is a unique treatment consideration for patients with AERD.
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http://dx.doi.org/10.1016/j.otc.2016.08.007DOI Listing
February 2017

The nasal vestibular body: anatomy, clinical features, and treatment considerations.

Eur Arch Otorhinolaryngol 2016 Mar 29;273(3):777-81. Epub 2016 Jan 29.

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

Nasal obstruction is a common presenting complaint, with many possible etiologies. Herein, we provide an introductory anatomic description, clinical relevance, and proposed nomenclature for an underappreciated soft tissue focus in the nasal vestibule-the nasal vestibular body (NVB)-that can contribute to nasal obstruction in a subset of patients. This is a small mound of dynamic soft tissue in the lateral aspect of the internal nasal valve, situated inferior and anterior to the head of the inferior turbinate that can be missed on routine examination for many salient reasons. In well-selected patients, whose symptoms of nasal obstruction may in part be secondary to the presence of this soft tissue focus, directed testing and tissue reduction can be performed.
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http://dx.doi.org/10.1007/s00405-015-3868-2DOI Listing
March 2016

Massive Sinonasal Polyposis.

JAMA Otolaryngol Head Neck Surg 2015 Jul;141(7):669-70

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas.

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http://dx.doi.org/10.1001/jamaoto.2015.0798DOI Listing
July 2015

Other asthma considerations.

Otolaryngol Clin North Am 2014 Feb 1;47(1):147-60. Epub 2013 Nov 1.

Department of Internal Medicine, Washington University, 660 Euclid, PO Box 8052, St. Louis, MO 63110, USA.

Asthma is a heterogeneous syndrome of cough, wheeze, dyspnea, and chest tightness. However, in a subset of patients, these symptoms may indicate a different underlying disease process with variable responsiveness to classic asthma therapies. Disease may progress while practitioners attempt conventional asthma therapy. Additionally, some types of asthma may require alternative approaches to relieve symptoms successfully. This article describes the differential diagnosis of asthma and discusses some of the more common asthma variants and asthma mimickers.
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http://dx.doi.org/10.1016/j.otc.2013.08.015DOI Listing
February 2014

Comparison of endoscopically-guided swab vs aspirate culture techniques in post-endoscopic sinus surgery patients: blinded, prospective analysis.

Int Forum Allergy Rhinol 2013 Sep 27;3(9):726-30. Epub 2013 Mar 27.

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX.

Background: Culture-directed antibiotic therapy remains imperative in the management paradigm of chronic rhinosinusitis (CRS). The objective of this study was to conduct a prospective, blinded comparison of endoscopically-guided swab and aspirate cultures from the same sinonasal site in patients presenting with acute infectious exacerbations post-sinus surgery.

Methods: Forty-nine CRS patients were prospectively enrolled in a tertiary care rhinology clinic. At the conclusion of the study, all cultures were unblinded to determine mean culture yield, most common pathogens, potential contaminants, and therapeutic correlation.

Results: The mean patient age was 49 years and 40.8% were males. All patients had evidence of symptomatic exacerbation with purulence on endoscopy at the time of presentation. There was a mean of 1.367 pathogens assayed per aspirate culture vs a mean of 1.102 per swab culture (p = 0.0032). The prevalence of Pseudomonas aeruginosa was 42% for aspirate vs 30% for swab cultures, respectively. The prevalence of Staphylococcus aureus was 49% for suction cultures vs 45% for swab cultures. There were 9 and 11 likely contaminants using aspirate and swab cultures, respectively. Therapeutic correlation was strong in 67%, moderate in 18%, and weak in 14% of patients.

Conclusion: This prospective analysis demonstrated higher culture yield, particularly with Pseudomonas, with aspirate vs swab cultures in postoperative patients. There is a strong clinical correlation between the 2 methods, and both aspirate and swab techniques serve as acceptable alternatives for endoscopic-guided cultures in patients with post-functional endoscopic sinus surgery infectious exacerbations.
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http://dx.doi.org/10.1002/alr.21170DOI Listing
September 2013

Management of electrode exposure after cochlear implantation.

Otol Neurotol 2012 Sep;33(7):1197-200

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9035, USA.

Background: Exposure of a cochlear implant electrode array in the middle ear or external auditory canal is an uncommon complication. We report a series of 7 patients with electrode array exposure, 5 of whom were managed without surgical intervention.

Objective: To report the outcomes of patients with electrode array exposure after cochlear implantation.

Study Design: Retrospective case series.

Setting: Tertiary neurotology practice.

Patients: Patients with cochlear implant electrode exposure in the middle ear or external auditory canal.

Main Outcome Measure: Length of observation without deterioration of implant function and without complications.

Results: Five patients were managed without revision surgery. One patient presented with a poorly functioning implant, but after reprogramming, the implant returned to its baseline performance. Four other patients required no reprogramming and were managed medically without deterioration of implant function. Follow-up time was between 2 and 6 years. There were no serious complications in any patient related to their cochlear implant.

Conclusion: Careful observation of patients with an exposed electrode array after cochlear implantation and a functioning implant seems to be a reasonable management option in select cases.
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http://dx.doi.org/10.1097/MAO.0b013e3182659b05DOI Listing
September 2012

Surgical management of frontal sinus inverted papilloma: a systematic review.

Laryngoscope 2012 Jun 27;122(6):1205-9. Epub 2012 Mar 27.

Department of Otolaryngology-Head and Neck Surgery and Comprehensive Skull Base Program, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA.

Objectives/hypothesis: Surgical management of frontal sinus (FS) inverted papilloma (IP) remains a significant challenge. This study systematically reviews the FS IP literature to delineate outcomes based on surgical strategy.

Study Design: Systematic review.

Methods: Cases for inclusion were identified by literature query for the terms frontal sinus and inverted papilloma between 1995 and 2010. Cases reported with sufficient outcomes data, defined as specific surgical approach and disease-free follow-up, were included. Statistical analysis was performed to identify significant risk factors for recurrence. The reported length of follow-up for each surgical approach was analyzed as an indicator of the strength of the reported literature for each approach.

Results: Fifty-seven cases were identified in 13 studies, with 49 cases deemed adequate for additional analysis. Twenty-four cases (49%) were primary, and 25 (51%) were secondary (residual or recurrent disease) IP. Bilateral FS involvement was reported in eight cases (16.3%). Surgical approaches employed included endoscopic frontal sinusotomy (EFS) in 21 (42.9%), endoscopic modified Lothrop (EML) in 10 (20.4%), osteoplastic flap in 13 (26.5%), and endoscopic trephination and EFS in five (10.2%) patients. The overall rate of recurrence was 22.4%. Mean follow-up time was 27 months.

Conclusions: The recent reported literature of FS IP demonstrates high prevalence of recurrent and bilateral cases. Although statistical analysis of this accrued data is unable to delineate the best surgical approach for FS IP, more aggressive approaches frequently employed for secondary or bilateral disease may facilitate better disease control.
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http://dx.doi.org/10.1002/lary.23275DOI Listing
June 2012