Publications by authors named "James A Stankiewicz"

40 Publications

Endoscopic Repair of Choanal Atresia: 33 Years Later.

Ear Nose Throat J 2020 May 13:145561320925194. Epub 2020 May 13.

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, USA.

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http://dx.doi.org/10.1177/0145561320925194DOI Listing
May 2020

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis.

Int Forum Allergy Rhinol 2016 Feb;6 Suppl 1:S22-209

Northwestern University.

Background: The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS).

Methods: Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus.

Results: The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS.

Conclusion: As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.
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http://dx.doi.org/10.1002/alr.21695DOI Listing
February 2016

Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations.

Rhinology 2016 06;54(2):99-104

Royal National Throat, Nose and Ear Hospital, University College London Hospitals, London, United Kingdom.

Background: Management of rhinosinusitis during pregnancy requires special considerations.

Objectives: 1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations.

Methods: The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea.

Results: Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations.

Conclusions: The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.
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http://dx.doi.org/10.4193/Rhino15.228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5797655PMC
June 2016

Medical and Surgical Complications in the Treatment of Chronic Rhinosinusitis.

Otolaryngol Clin North Am 2015 Oct 14;48(5):xv-xvi. Epub 2015 Jul 14.

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center/Trinity Health Center, 2160 South First Avenue, Maywood, IL 60153, USA. Electronic address:

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http://dx.doi.org/10.1016/j.otc.2015.07.001DOI Listing
October 2015

Medicolegal Issues in Endoscopic Sinus Surgery and Complications.

Otolaryngol Clin North Am 2015 Oct 26;48(5):827-37. Epub 2015 Jun 26.

Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA.

Complications occur during and after endoscopic sinus surgery. Complications leading to temporary or most commonly permanent injury often are involved in litigation for malpractice. This article concentrates on areas of importance that are considered during medicolegal deliberations.
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http://dx.doi.org/10.1016/j.otc.2015.05.014DOI Listing
October 2015

Contemporary management of frontal sinus mucoceles: a meta-analysis.

Laryngoscope 2014 Feb 6;124(2):378-86. Epub 2013 Aug 6.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, Arizona.

Objectives/hypothesis: To analyze trends in the surgical management of frontal and fronto-ethmoid mucoceles through meta-analysis.

Study Design: Meta-analysis and case series.

Methods: A systematic literature review on surgical management of frontal and fronto-ethmoid mucoceles was conducted. Studies were divided into historical (1975-2001) and contemporary (2002-2012) groups. A meta-analysis of these studies was performed. The historical and contemporary cohorts were compared (surgical approach, recurrence, and complications). To study evolution in surgical management, a senior surgeon's experience over 28 years was analyzed separately.

Results: Thirty-one studies were included for meta-analysis. The historical cohort included 425 mucoceles from 11 studies. The contemporary cohort included 542 mucoceles from 20 studies. More endoscopic techniques were used in the contemporary versus historical cohort (53.9% vs. 24.7%; P = <0.001). In the authors' series, a higher percentage was treated endoscopically (82.8% of 122 mucoceles). Recurrence (P = 0.20) and major complication (P = 0.23) rates were similar between cohorts. Minor complication rates were superior for endoscopic techniques in both cohorts (P = 0.02 historical; P = <0.001 contemporary). In the historical cohort, higher recurrence was noted in the external group (P = 0.03).

Conclusions: Results from endoscopic and open approaches are comparable. Although endoscopic techniques are being increasingly adopted, comparison with our series shows that more cases could potentially be treated endoscopically. Frequent use of open approaches may reflect efficacy, or perhaps lack of expertise and equipment required for endoscopic management. Most contemporary authors favor endoscopic management, limiting open approaches for specific indications (unfavorable anatomy, lateral disease, and scarring).

Level Of Evidence: N/A.
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http://dx.doi.org/10.1002/lary.24309DOI Listing
February 2014

Interrater agreement of nasal endoscopy in patients with a prior history of endoscopic sinus surgery.

Int Forum Allergy Rhinol 2012 Nov 13;2(6):453-9. Epub 2012 Jun 13.

Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY 10003, USA.

Background: Nasal endoscopy is an important part of the clinical evaluation of patients with chronic rhinosinusitis. However, the objectivity and interrater agreement of the procedure related findings have not been well studied, especially in patients who have previously had sinus surgery.

Methods: Patients with a history of endoscopic sinus surgery for chronic rhinosinusitis were prospectively enrolled from a tertiary rhinology practice. Fourteen endoscopic nasal examinations were recorded using digital video capture software. Each patient also underwent computed tomography (CT) and completed the Sinonasal Outcome Test (SNOT-22). Blinded review of inflammatory and anatomic findings for each video was independently performed by 5 academic rhinologists at separate institutions. Comparisons were performed using the unweighted Fleiss' kappa statistic (K(f) ) and the prevalence- and bias-adjusted kappa (PABAK).

Results: There were no significant correlations between age, Lund-Mackay score, or SNOT-22 score. Interrater agreement was variable across the characteristics studied. Mean PABAK was excellent for the assessment of polyps (K(f) = 0.886); moderate for the assessments of middle turbinate (MT) integrity (K(f) = 0.543), MT position (K(f) = 0.443), maxillary sinus patency (K(f) = 0.593), and ethmoid sinus patency (K(f) = 0.429); fair for discharge (K(f) = 0.314), synechiae (K(f) = 0.257), and middle meatus patency (K(f) = 0.229); and poor for MT mucosal changes (K(f) = 0.148) and uncinate process (K(f) = 0.126).

Conclusion: This study was notable for variability in the interrater agreement among the inflammatory and anatomic attributes that were examined. Further standardization of nasal endoscopy with regard to interpretation may improve the reliability of this procedure in clinical practice.
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http://dx.doi.org/10.1002/alr.21058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448826PMC
November 2012

Effect of lumbar drain placement on recurrence of cerebrospinal rhinorrhea after endoscopic repair.

Int Forum Allergy Rhinol 2012 May-Jun;2(3):222-6. Epub 2012 Feb 16.

Department of Otolaryngology-Head and Neck Surgery, Division of Neurosciences, Stritch School of Medicine, Loyola University Hospital, Maywood, IL 60153, USA.

Background: Lumbar drain (LD) use in the management of cerebrospinal fluid (CSF) rhinorrhea remains controversial. We analyzed the relationship between LD placement and CSF leak recurrence after endoscopic repair.

Methods: A retrospective case series was conducted. Patients who underwent CSF leak repair from 1999 to 2010 were identified. Data collected included demographics, body mass index (BMI), history of obstructive sleep apnea (OSA) or idiopathic intracranial hypertension (IIH), associated meningoencephalocele, etiology and site of leak, LD placement, fluorescein and antibiotic use, recurrence, and site of recurrence. Correlation between LD placement and leak recurrence was analyzed.

Results: A total of 105 patients underwent CSF leak repair. A total of 68 patients had an LD. Of these 68 patients, 15 (22%) had a recurrent leak. Of the 105 patients, 37 did not have an LD, and 5 of the 37 (14%) recurred. Recurrence rates with and without LD were not significantly different (p = 0.15). Of the 105 patients, 40 (38%) had a spontaneous leak, 15 (14%) had a traumatic leak, and 50 (48%) had an iatrogenic leak. In the spontaneous group, 30 of 40 patients had an LD and 10 of 40 did not. Recurrence was not significant between these subgroups (p = 1.0). LD was used in 11 of 15 patients with traumatic leaks. Of these 15 patients, 4 did not have a drain. Recurrence was not significant between these subgroups (p = 1.0). In 27 of 50 patients with an iatrogenic leak, an LD was placed. Of 50 patients, 23 did not have an LD. There was no statistical significance when the recurrence rates for these subgroups were compared (p = 0.26).

Conclusion: In our study, there was no association identified between LD placement and recurrence rates after endoscopic repair of CSF rhinorrhea.
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http://dx.doi.org/10.1002/alr.21023DOI Listing
August 2012

Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study.

Int Forum Allergy Rhinol 2011 Jul-Aug;1(4):235-41. Epub 2011 Jun 6.

Division of Rhinology and Sinus Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA.

Background: Evidence evaluating the comparative effectiveness of various treatments for chronic rhinosinusitis (CRS) is insufficient. This study evaluates outcomes in patients who failed initial medical management and elect a subsequent treatment option, either continued medical management or endoscopic sinus surgery (ESS) coupled with continued medical management.

Methods: Adult subjects were prospectively enrolled into a nonrandomized, multi-institutional cohort. Baseline characteristics and objective clinical findings were collected. Primary outcome measures included 2 disease-specific quality-of-life (QOL) instruments: the Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS). Bivariate and multivariate analyses compared QOL improvement by treatment type, as well as differences in antibiotic and oral steroid utilization and work/school productivity.

Results: Subjects (n = 180) were enrolled between March 2009 and April 2010. Patients electing medical management (n = 55) reported significantly better baseline QOL on 1 instrument relative to surgery patients (CSS symptom [p = 0.019] and total scores [p = 0.010]). Surgical patients (n = 75) reported significantly more improvement than medically managed patients (RSDI, p = 0.015; CSS, p < 0.001). Surgical patients reported significantly fewer oral antibiotics (p = 0.002), oral steroids (p = 0.042), and missed days of work/school (p < 0.001) following ESS. After adjustment, more frequent improvement was found within the surgical cohort as measured by the RSDI physical (78.7% vs 56.4%; odds ratio [OR], 3.36; 95% confidence interval [CI], 1.15-9.87; p = 0.027), CSS symptom (80.6% vs 57.4%; OR, 2.65; 95% CI, 1.06-6.66; p = 0.038), medication (49.3% vs 29.6%; OR, 2.33; 95% CI, 0.96-5.64; p = 0.060), and total scores (76.4% vs 53.7%; OR, 2.20; 95% CI, 0.86-5.59; p = 0.099).

Conclusion: Patients electing ESS experienced significantly higher levels of improvement in several outcomes. Further investigation with a larger cohort is warranted as treatment selection bias may confound the magnitude of improvement experienced with each treatment.
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http://dx.doi.org/10.1002/alr.20063DOI Listing
May 2012

Interrater agreement of nasal endoscopy for chronic rhinosinusitis.

Int Forum Allergy Rhinol 2012 Mar-Apr;2(2):144-50. Epub 2012 Jan 17.

Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA.

Background: Nasal endoscopy is a routine, important diagnostic tool in the evaluation of chronic rhinosinusitis (CRS). Although the procedure is ideally "objective," the subjective nature of endoscopy interpretation and lack of standardization are potential limitations. The goal of this study was to examine the interrater agreement of various categories of nasal endoscopy findings in patients undergoing evaluation for CRS.

Methods: Fourteen patients (28 sides) with CRS underwent clinical evaluation, SNOT-22, sinus computed tomography (CT), and digital video nasal endoscopy. Five academic rhinologists blindly reviewed the endoscopies for structural anatomic issues, inflammatory rhinosinusitis findings, and atypical lesions. Statistical comparison of the endoscopy interpretations was performed using the unweighted Fleiss' kappa statistic (K(f) ).

Results: The mean Lund-Mackay CT scan score was 7.8 (standard deviation [SD] 4.9) and the mean SNOT-22 score was 35.8 (SD 22.7). Significant variability was noted among the raters with respect to the various categories of nasal endoscopy findings. The overall levels of interrater agreement for the various categories were as follows: "almost perfect" for atypical lesions (K(f) = 0.912); "substantial" for nasal polyps (K(f) = 0.693); "moderate" for nasal discharge (K(f) = 0.422) and mucosal inflammatory changes of the middle turbinate (K(f) = 0.413); and "fair" for edema of the middle meatus (K(f) = 0.214), obstruction by nasal septum deviation (K(f) = 0.240), and obstruction by the middle turbinate (K(f) = 0.276).

Conclusion: Significant variability was noted in the interrater agreement for nasal endoscopy findings in this study, with relatively limited agreement on some of the key findings of the procedure. Additional investigation and standardization of nasal endoscopy interpretation is required to improve the clinical utility of the procedure.
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http://dx.doi.org/10.1002/alr.21009DOI Listing
August 2012

Complications in endoscopic sinus surgery for chronic rhinosinusitis: a 25-year experience.

Laryngoscope 2011 Dec 15;121(12):2684-701. Epub 2011 Nov 15.

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.

Objectives/hypothesis: The aim of this study was to review complications occurring as a result of endoscopic sinus surgery by one surgeon in an academic practice during a 25-year period.

Study Design: Retrospective clinical study.

Methods: A register of complications was tabulated during a period of 25 years for endoscopic sinus surgery performed for chronic rhinosinusitis in 3,402 patients (6,148 sides). All complications were reviewed as a whole and were not divided into major or minor categories.

Results: A total of 105 patients were found to have complicated endoscopic sinus surgery, for an overall patient complication rate of 0.031, or 0.017 per operated side. The most common complications were hemorrhage (n = 41), orbital complications (n = 29), and CSF leak (n = 19). The following factors were noted to have increased risk for complications: age, revision surgery, nasal polyps, anatomic variation, extensive disease, overall health, medications, and underlying factors. Certain types of instrumentation such as powered instrumentation placed patients at greater risk. The use of image guidance or surgical experience did not eliminate complications from occurring.

Conclusions: Complications of endoscopic sinus surgery still occur 25 years after the initial introduction of the surgery in 1985. Many complications can be managed without a bad outcome. The key to prevention is knowledge of anatomy, preparation, anticipation, and experience. Even then, complications can occur in the most experienced hands. Patients most at risk for complications include those with revision surgery, extensive disease, skull base anatomic or radiologic variations or dehiscences related to disease or previous surgery, and the use of powered instrumentation.
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http://dx.doi.org/10.1002/lary.21446DOI Listing
December 2011

Obstructing encephaloceles presenting as chronic rhinosinusitis: lessons learned from a case series.

Ann Otol Rhinol Laryngol 2011 Jul;120(7):474-7

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, 2160 S First Ave, Maguire Building, Maywood, IL 60153, USA.

We present a unique anatomic cause of encephalocele, and describe appropriate diagnosis. Two patients underwent stereotactic image-guided sinus surgery for presumed chronic rhinosinusitis with intraoperative findings of a sinus encephalocele. The first patient underwent a conservative 2-stage management that included an initial cerebrospinal fluid (CSF) leak repair followed by encephalocele resection. The second patient underwent a 1-stage encephalocele resection and CSF leak repair with a septal graft. The sinus surgeon needs to consider the possibility of encephalocele when the ethmoid, sphenoid, or, rarely, frontal sinuses present with an isolated opacification that does not improve with conservative medical therapy.
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http://dx.doi.org/10.1177/000348941112000709DOI Listing
July 2011

Application of minimally invasive endoscopic sinus surgery techniques.

Otolaryngol Clin North Am 2010 Jun;43(3):565-78, ix

Department of Otolaryngology-Head & Neck Surgery, Loyola University Medical Center, 2160 South First Avenue, Magquire Building, Maywood, IL 60153, USA.

New instrumentation and techniques for endoscopic sinus surgery (ESS) are presently available that offer the potential of successfully treating recalcitrant chronic rhinosinusitis is a manner that minimizes operative times, sinus-mucosal trauma, and operative costs. This content describes current ESS techniques and quality-of-life outcomes, techniques for transnasal and transantral balloon catheter dilatation, and their outcomes. The authors address the changing medical climate that may open new avenues for surgeons to treat patients.
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http://dx.doi.org/10.1016/j.otc.2010.02.021DOI Listing
June 2010

Diagnosis and management of chronic rhinosinusitis in adults.

Postgrad Med 2009 Nov;121(6):121-39

UT-Southwestern Medical Center, Department of Otolaryngology-Head and Neck Surgery, Dallas, TX 75390-7208, USA.

Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.
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http://dx.doi.org/10.3810/pgm.2009.11.2081DOI Listing
November 2009

A contemporary review of endoscopic sinus surgery: techniques, tools, and outcomes.

Laryngoscope 2009 Nov;119(11):2258-68

Department of Otolaryngology-Head and Neck Surgery, Loyola University School of Medicine, Maywood, Illinois, USA.

Chronic rhinosinusitis is estimated to nearly 25 million people annually in the United States alone. The medical management of these patients is often successful; however, when medical management fails, surgery may be indicated to bring relief. Unfortunately, surgery for chronic rhinosinusitis is not standardized and we remain without a consensus on both the extent of surgery required and the manner in which it is performed. In the past 25 years, three philosophies or schools of thought have arisen to help guide the surgical treatment of chronic rhinosinusitis. Functional endoscopic sinus surgery aims to surgically treat problem areas by ventilating the sinuses through the natural ostia and addressing all diseased sinuses when necessary. This procedure is not standardized and is patient and surgeon dependent. The minimally invasive sinus technique has been proposed as a method whereby each surgical procedure is standardized regardless of disease severity. Lastly, balloon catheter dilatation of the sinus ostia, which by itself is not truly a procedure, is also discussed as a separate philosophy since these specific tools used during endoscopic sinus surgery have quickly energized the sinus community. All three schools of thought possess benefits and drawbacks, even when used appropriately. The concepts, tools, and technologies will be reviewed here as well as outcomes in the hopes that this article will provide an understanding of the surgical options to successfully treat chronic rhinosinusitis.
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http://dx.doi.org/10.1002/lary.20618DOI Listing
November 2009

Efficacy of targeted medical therapy in chronic rhinosinusitis, and predictors of failure.

Am J Rhinol Allergy 2009 Jul-Aug;23(4):396-400

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.

Background: No standardized medical therapy for chronic rhinosinusitis (CRS) is universally accepted. Success of medical therapy is reportedly 50% to 88%, but studies differ in inclusion criteria, medications, duration of therapy, and defining "success." The objectives of this study were to determine efficacy of a standardized targeted medical therapy (TMT) regimen in CRS and to analyze factors associated with failure of therapy.

Methods: Retrospective analysis of prospectively collected data was performed. CRS was diagnosed based on CRS Taskforce guidelines. TMT was defined as a minimum 4-week treatment with oral antibiotics, oral steroids, topical nasal steroids, topical nasal decongestant rotation, and saline nasal douching. "Failure" was defined as relapse/persistence of signs/symptoms or need for surgery. One hundred forty-five patients that received TMT, with a minimum 2-month follow-up, were identified. The results of therapy were reviewed to determine efficacy and analyze factors associated with failure.

Results: Seventy-four patients (51.03%) were successfully treated. Failures included 26 patients (17.8%) with only partial improvement and 45 (31.03%) who underwent surgery. Only history of facial pressure/pain (p = 0.049), presence of mucosal inflammation (p = 0.013), and higher endoscopic severity grade (p = 0.011) were associated with failure of TMT.

Conclusions: TMT was unequivocally successful in 51% of patients. Failures included 31% who underwent surgery and 18% with partial benefit. Surgery was avoided in 69%. Facial pressure/pain, mucosal inflammation, and higher endoscopic severity grade were associated with failure of medical therapy.
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http://dx.doi.org/10.2500/ajra.2009.23.3334DOI Listing
October 2009

Antifungal treatment and chronic rhinosinusitis.

Curr Allergy Asthma Rep 2009 May;9(3):227-31

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Building 105, Room 1870, 2160 South 1st Avenue, Maywood, IL 60153, USA.

Chronic rhinosinusitis (CRS) is an inflammatory disease with a multifactorial etiology. Antifungal therapy is not routinely used to treat it. However, evidence implicating fungi in some forms of CRS recently has been published. Controversy exists as to whether fungi identified in sinonasal cultures are always pathogenic. Immunologic evidence supporting the role of fungi in the pathogenesis of CRS is also debated. Topical antifungal therapy is more widely used than oral therapy, with amphotericin B irrigation being the most common. Although some studies show benefit from this irrigation, others refute the efficacy. Although oral antifungal agents are used uncommonly, itraconazole is the most commonly used drug. The efficacy of oral itraconazole in CRS has never been assessed in a clinical trial. Given the current evidence, the use of antifungals to treat CRS is controversial and has limited indications.
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http://dx.doi.org/10.1007/s11882-009-0033-2DOI Listing
May 2009

Nasal amphotericin irrigation in chronic rhinosinusitis.

Curr Opin Otolaryngol Head Neck Surg 2008 Feb;16(1):44-6

Department of Otolaryngology - Head & Neck Surgery, Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois 60153, USA.

Purpose Of Review: To review the literature on the use of amphotericin irrigation for the treatment of chronic rhinosinusitis.

Recent Findings: Although the etiology of acute rhinosinusitis is usually bacterial in nature, the exact etiology of chronic rhinosinusitis is unclear. Recent literature reports pointed to fungal colonization as a likely pathogenesis. It was hypothesized that a nonallergic eosinophilic immunoglobulin response to these fungi by the host was the cause of the symptoms, not a fungal invasion into the mucosa. The paper reviews the most recent articles investigating the use of amphotericin irrigation, as well as sprays and oral medications, of the nasal and sinus mucosa in patients with chronic rhinosinusitis.

Summary: The use of amphotericin for patients with chronic rhinosinusitis is not substantiated by the majority of publications. Although some studies found improvement on radiographic images, the symptoms of the disorder were not improved even with fungal eradication. Further studies need to be carried out to determine if changes in dosage, treatment time or route of administration could improve results.
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http://dx.doi.org/10.1097/MOO.0b013e3282f1c7baDOI Listing
February 2008

Chronic rhinosinusitis and psoriasis: do mutually exclusive systemic Th1 and Th2 disease patterns exist?

Acta Otolaryngol 2007 Jul;127(7):780-3

MD PhD Department, Loyola University, Maywood, IL 60153, USA.

Conclusion: Our results support the theory that chronic rhinosinusitis (CRS) is a systemic Th alteration, the relevance of which is discussed in detail.

Objective: CRS imposes a heavy burden on society; however, a reliable CRS therapy has not been found. Developing a better understanding of this pathology will help us in our search for more effective therapies. One question, which is rarely examined, is the possibility of CRS existing as a systemic immune alteration in Th response. Thus, the goal of this study was to examine the occurrence of CRS, a Th2 pathology, with Th1 pathologies such as psoriasis.

Patients And Methods: This study was performed via a retrospective electronic query of our medical center in regards to patients coded with the respective diagnosis.

Results: Analysis of the data showed that occurrence of CRS rarely coincided with the occurrence of psoriasis and other such Th1 pathologies.
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http://dx.doi.org/10.1080/00016480601002054DOI Listing
July 2007

Surgical outcomes following the endoscopic modified Lothrop procedure.

Laryngoscope 2007 May;117(5):765-9

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA.

Objective: We performed a systematic review of 97 patients in whom an entirely endoscopic modified Lothrop procedure (EMLP) was performed. We studied the safety, efficacy, need for revision surgery, and rate of complication following an EMLP.

Study Design: The study design was a retrospective chart analysis.

Methods: We performed a retrospective chart review and patient survey of 97 patients who underwent an EMLP at our institution from January 1999 to March 2006. Main outcomes measured were the need for revision surgery including an osteoplastic flap (OPF), improvement in patients' symptoms, and rate of cerebrospinal fluid (CSF) leak.

Results: The most common indication for the procedure was chronic frontal sinusitis and/or formation of mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. CSF leak rate was 1% (1/97) and was managed successfully at the time of surgery without any long-term sequelae. Twenty-two (23%) patients required revision surgery. Three (3%) patients required revision with an OPF. Some degree of symptomatic clinical improvement was reported by 98% (95/97) of patients.

Conclusion: EMLP is a safe and effective surgical alternative to OPF for patients with recalcitrant frontal sinus disease. Major complications are rare. A large percentage of patients may require revision surgery.
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http://dx.doi.org/10.1097/MLG.0b013e3180337d7bDOI Listing
May 2007

Activity of nasal amphotericin B irrigation against fungal organisms in vitro.

Am J Rhinol 2007 Mar-Apr;21(2):145-8

Departments of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.

Background: The role of fungi in chronic rhinosinusitis has been described in recent reports. Controversy exists on the use of topical amphotericin B therapy as a treatment modality for this condition. The effect of various concentrations of amphotericin B nasal irrigation on actively growing fungi was studied in vitro.

Methods: Ten species of fungi commonly found in the nasal cavity were grown on growth media plates. Each fungi was exposed to 20 mL of amphotericin B nasal irrigation at concentrations of either 100, 200, or 300 microg/mL or sterile water two times daily for 6 weeks. Each plate was subcultured on a weekly basis to examine for any viable fungi.

Results: Fungi growth was not arrested in the 100-microg/mL amphotericin B and sterile water groups at the end of 6 weeks. Use of the 300-and 200-microg/mL amphotericin B solutions showed failure of the subcultured fungi to grow at 5 and 6 weeks, respectively.

Conclusion: Nasal amphotericin B irrigation is ineffective in killing fungi in vitro at a concentration of 100 microg/mL over a 6-week period. Concentrations of 200 and 300 lig/mL successfully prevented fungi growth at the conclusion of the study. The current concentration of commercially available topical amphotericin B (100 microg/mL) seems ineffective in eradicating fungi in vitro.
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http://dx.doi.org/10.2500/ajr.2007.21.2988DOI Listing
June 2007

Long-term outcomes of endoscopic repair of cerebrospinal fluid leaks and meningoencephaloceles.

Am J Rhinol 2005 Nov-Dec;19(6):582-7

Department of Otolaryngology-Head and Neck Surgery, Tulane University, New Orleans, Louisiana, USA.

Background: The management and surgical approach to cerebrospinal fluid (CSF) leaks and meningoencephaloceles have undergone transformation throughout the last 10 years. It is our interest to examine the long-term surgical outcome and reoccurrence rates of CSF leaks or meningoencephaloceles in patients having endoscopic surgical repair.

Methods: We performed a retrospective evaluation of 50 patients that underwent endoscopic surgical repair of a CSF leak, meningoencephalocele, or both, between September 1985 and October 2003.

Results: Cumulatively, reoccurrence rates were 15% (7/47) among the CSF leak patients with an average time frame for reoccurrence ranging from 1 to 25 months (average, 7 months). Patients with meningoencephaloceles had an overall reoccurrence rate of 8% (1/13). In addition, a Medline search on CSF leaks and meningoencephaloceles provided the names of 32 authors that have studied outcomes of endoscopic surgical repair. Of the 151 patients still followed in the 5- to 10-year postoperative group, there were 37 recurrences of CSF leaks and 5 reoccurrences of the meningoencephaloceles with a total recurrence rate of 27% (37 + 5/151). Of the 19 patients still followed in the >10-year postoperative group, there were three reoccurrences of CSF leaks and no reoccurrences of meningoencephaloceles, giving a reoccurrence rate of 16% (3 + 0/19).

Conclusion: Based on our cumulative results, a reoccurrence of a CSF leak or meningoencephalocele after endoscopic repair will occur within the first 2 years postoperatively. Once patients pass these postoperative time frames they are relatively free of reoccurrence from this very effective surgical management. Endoscopic repair results are better than craniotomy with much less morbidity.
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April 2006

Application of image-guidance to surgery of the orbit.

Otolaryngol Clin North Am 2005 Jun;38(3):491-503

Department of Otolaryngology-Head and Neck Surgery, 2160 South First Avenue, Building 105, Loyola University Medical Center, Maywood, IL 60153, USA.

CAS can be useful in orbital surgery. It can help to identify various structures, although it is certainly not necessary, nor is it a replacement for knowledge of the orbit's anatomy and its relationship to surrounding structures.
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http://dx.doi.org/10.1016/j.otc.2004.10.022DOI Listing
June 2005

Routine histopathology in uncomplicated sinus surgery: is it necessary?

Otolaryngol Head Neck Surg 2005 Mar;132(3):407-12; discussion 413

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, USA.

Objective: To evaluate the incidence of occult pathology in routine, uncomplicated endoscopic sinus surgery, and to suggest guidelines for when to send specimens for histopathologic exam.

Study Design And Setting: Retrospective analysis of case records of 790 patients who underwent 868 endoscopic sinus surgeries at a tertiary care center from 1986 to 2003. Indications were chronic sinusitis, recurrent acute sinusitis, nasal polyposis, or combinations of these diagnoses. All cases were considered routine and did not involve preoperative suspicion of neoplasm or other complicating factors. Charts were reviewed for surgical indication, patient age, laterality of disease, history of prior sinus surgery, intraoperative suspicion of tumor, and final histopathology.

Results: In 868 cases of endoscopic sinus surgery, occult neoplasm was diagnosed in 2 patients (0.23%). In one patient, the initial surgery cured the lesion. Final histopathology of the remaining 866 (99.8%) specimens was consistent with inflammation and/or nasal polyposis. In 121 cases of unilateral sinusitis, none was positive for neoplasm. In 277 cases involving bilateral nasal polyposis and 13 involving unilateral polyposis, no neoplasms were found. Intraoperative suspicion of neoplasm occurred in 12 cases, with all specimens read as consistent with sinusitis and/or polyposis.

Conclusions: Histopathologic review of every specimen obtained in routine sinus surgery for sinusitis and/or nasal polyposis is not indicated. Submission of specimen is indicated in routine cases when: 1) there is intraoperative suspicion of tumor, 2) unilateral nasal polyposis is present, 3) unilateral sinus opacification is present, and 4) additional diagnostic information is needed (eg, presence of eosinophils, fungal forms, etc.).

Significance: Establishes a safe and reasonable standard of care, with potential cost savings and medico-legal ramifications.
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http://dx.doi.org/10.1016/j.otohns.2004.10.002DOI Listing
March 2005

The low skull base-is it important?

Curr Opin Otolaryngol Head Neck Surg 2005 Feb;13(1):19-21

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.

Purpose Of Review: Little is published regarding variations of skull-base anatomy and their relevance to the performance of endoscopic sinus surgery. Several catastrophic complications have occurred in patients with low-lying skull-base variation. This review's purpose is to make the reader aware of skull-base variation, their recognition, and a surgical plan for sinus surgery in these patients.

Recent Findings: Only a few papers are available for review discussing variations of the low-skull base. Recent findings in reviewing multiple CT scan indicate several variations of the skull. It has also been noted that there are variations of thickening in the skull (ie, lateral ethmoid, thicker bone, more medial, thinner bone). Several case reports have surfaced reflecting how a low-lying skull-base can play a role in brain-related complications. These figures are reviewed.

Summary: A knowledge of orbital and skull-base variations preoperatively can help plan the surgical procedure and avoid major complication. The preoperative CT scan is the key to preoperative knowledge. The use of special techniques to aid in localization of a low-lying skull-base including image computer guidance is recommended.
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http://dx.doi.org/10.1097/00020840-200502000-00006DOI Listing
February 2005

Lidocaine for the relief of incapacitating tinnitus.

Ear Nose Throat J 2004 Apr;83(4):236-8

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Ill 60153, USA.

Tinnitus is tolerated by most patients, but in others it is enough of a problem that they seek medical attention. Results of treatment have been mixed. On occasion, a patient is so distressed by tinnitus that he or she is incapacitated and seeks help in an emergency department. We describe what we believe is the first reported case of recurrent incapacitating tinnitus secondary to inner ear tertiary syphilis in which a patient successfully responded to emergency treatment with intravenous lidocaine.
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April 2004

The low skull base: an invitation to disaster.

Am J Rhinol 2004 Jan-Feb;18(1):35-40

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.

Background: Knowledge of anatomy including variations observed with endoscopy or computerized tomography scan is vital to the performance of safe endoscopic sinus surgery. The lower-than-normal skull base/cribriform plate is an anatomic variation, which if not noted preoperatively, can lead to entrance into the brain causing major injury.

Methods: Four case studies of chronic rhinosinusitis are reviewed in which either the whole anterior skull base or the cribriform plate is lower than usual and major complications occurred.

Results: All four cases had unilateral or bilateral entrance into the skull base/cribriform plate of the brain in the biopsy specimen, postoperative cerebrospinal fluid leak, and/or brain hemorrhage. One patient died from the injury, three patients had marked neurological sequelae. The low skull base and its meaning for the surgeon is discussed at length.

Conclusion: The preoperative anatomy as determined by endoscopy and computerized tomography scanning has to be identified. Variations or abnormalities should be noted and taken into consideration for preoperative and operative planning. Failure to note skull base or cribriform anatomy variations may lead to brain entrance, injury, and death.
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June 2004

Nasal endoscopy and control of epistaxis.

Curr Opin Otolaryngol Head Neck Surg 2004 Feb;12(1):43-5

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.

Purpose Of Review: This review is designed to update the reader on the current state of nasal endoscopy in the control of epistaxis. Recent articles are reviewed and demonstrate recent developments and results.

Recent Findings: The use of endoscopy for control of anterior and posterior epistaxis is beneficial, with less morbidity then external procedures or Caldwell Luc approaches. Postoperative endoscopic sinus surgery epistaxis is easily treated with endoscopic visualization. Epistaxis secondary to tumors can be controlled via an endoscopic approach. Patients with Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia) can have more selective laser control of telangiectasia using endoscopic technique. Endoscopic septodermoplasty is straight-forward and avoids external incisions. Following a protocol for control of hemorrhage from an injured carotid artery during endoscopic sinus surgery, patients can survive with good function.

Summary: Endoscopic visualization and techniques are the state of the art for surgical control of epistaxis. Alternatives are embolization or external/Caldwell-Luc approaches.
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http://dx.doi.org/10.1097/00020840-200402000-00012DOI Listing
February 2004

The endoscopic modified Lothrop procedure for salvage of chronic frontal sinusitis after osteoplastic flap failure.

Otolaryngol Head Neck Surg 2003 Dec;129(6):678-83

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL 60153, USA.

Objective: While reported results utilizing the osteoplastic flap procedure are very good, some patients fail the surgery due to recurrent or persistent frontal sinus disease. This study was performed to evaluate the utility of the endoscopic modified Lothrop sinus surgery for osteoplastic flap failure.

Study Design And Setting: A retrospective chart analysis and telephone survey of 10 patients from outside our institution for whom an osteoplastic flap with fat obliteration failed were salvaged using a computerized endoscopic modified Lothrop procedure.

Results: The main complaints were headache/pressure and recurrent infection. The usual pathology was chronic sinusitis and/or mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. Symptomatic clinical improvement was noted in more than 90% of patients.

Conclusion: Salvage endoscopic modified Lothrop sinus surgery is recommended for a limited number of traditional osteoplastic flap failures. Computerized surgical navigation may help avoid complications in situations with abnormal anatomy and previous dissection.

Significance: The endoscopic modified Lothrop procedure should be considered to salvage failed osteoplastic flap sinus obliteration.
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http://dx.doi.org/10.1016/j.otohns.2003.07.011DOI Listing
December 2003

Endoscopic and imaging techniques in the diagnosis of chronic rhinosinusitis.

Curr Allergy Asthma Rep 2003 Nov;3(6):519-22

Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA.

The definition of chronic rhinosinusitis globally applies to any patient who has nasal and/or sinus inflammatory disease for a period of more than 3 months, provided the patient has particular signs and symptoms. However, to treat chronic rhinosinusitis appropriately, specific etiologies must be diagnostically ruled in or out. Chronic rhinosinusitis can be complex, because there are several factors involved in its causation. Endoscopy and imaging can play a role in helping to lead to a more specific diagnosis, allowing more targeted treatment.
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http://dx.doi.org/10.1007/s11882-003-0064-zDOI Listing
November 2003
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