Publications by authors named "Peter H Hwang"

180 Publications

Multi-compartment skull base orbital cavernous venous malformation: A rare presentation of a common orbital mass.

Am J Ophthalmol Case Rep 2021 Mar 21;21:101020. Epub 2021 Jan 21.

Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA.

Purpose: We present a unique case of an orbital intraconal cavernous venous malformation that extended along the trigeminal nerve to the pterygopalatine and middle cranial fossa. Our aim is to describe an atypical presentation of this common orbital vascular mass.

Observations: A 57-year-old female presented with right eye proptosis. Orbital magnetic resonance imaging demonstrated a lobulated contrast-enhancing mass involving the right intraconal orbital space, pterygopalatine fossa, and right middle cranial fossa, radiographically presumed to be a schwannoma. Intraoperative and histopathologic evaluation confirmed a cavernous venous malformation that extended along the trigeminal nerve. The mass, including its attachments to the cranial nerves and dura, was successfully removed via a combined transorbital and endoscopic endonasal approach. The patient recovered well with 20/20 vision, full extraocular movements, and resolution of proptosis.

Conclusions: This a rare presentation of an orbital cavernous venous malformation not previously described. Cavernous venous malformations typically present as ovoid well-circumscribed lesions; however, they can also extend outside the orbit along the path of cranial nerves, as was observed in this case. These types of lesions should be included in the differential diagnosis of masses arising from or extending along cranial nerves, even when involving the orbit.
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http://dx.doi.org/10.1016/j.ajoc.2021.101020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868709PMC
March 2021

5-year outcomes of salvage endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma.

J Otolaryngol Head Neck Surg 2021 Feb 17;50(1):12. Epub 2021 Feb 17.

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

Objective: Recurrent nasopharyngeal carcinoma (rNPC) can be salvaged with re-irradiation, open nasopharyngectomy, and more recently endoscopic nasopharyngectomy. However, long-term outcomes of endoscopic approaches are lacking. Thus, we report 5-year outcomes following endoscopic nasopharyngectomy for rNPC.

Methods: Patients who underwent endoscopic nasopharyngectomy for rNPC between January 2000 and January 2012 were retrospectively reviewed. Patients were included if they had their first endoscopic nasopharyngectomy at least 5 years prior to this study. Presenting (cTNM) status and recurrent (rTNM) status for each recurrence was determined. Outcomes included margin status, disease recurrence, death, and complication rates.

Results: Thirteen patients were included. Four patients had a prior open nasopharyngectomy. Mean time follow-up was 74.3 months (range = 56.4-96 months). Negative margins were achieved in 77% of initial cases. Positive margins were associated with higher rT stages. Re-recurrence was seen in 6 patients, which was also associated with a higher cStage and rStage. All patients with positive margins had re-recurrence. Four patients required repeat endoscopic nasopharyngectomy and two received chemoradiation. All four with a second endoscopic procedure had further disease recurrence. Five-year local disease-free and overall survival rates were 53.9 and 84.6%, respectively. The minor complication rate was 52.6%, major operative complication rate was 0.0%, and late complication rate was 23.1%.

Conclusion: Endoscopic nasopharyngectomy demonstrates promising 5-year overall survival rate for rT1 and rT2 cases of rNPC with favorable complication rates. Lower rStages were associated with a higher disease-free rate, and lower cStages were associated with improved overall prognosis. Close surveillance and prompt management of recurrences can be associated with favorable long-term tumor control.

Level Of Evidence: 4.
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http://dx.doi.org/10.1186/s40463-020-00482-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888158PMC
February 2021

Somatostatin receptor 2 expression in nasopharyngeal cancer is induced by Epstein Barr virus infection: impact on prognosis, imaging and therapy.

Nat Commun 2021 01 5;12(1):117. Epub 2021 Jan 5.

UCL Cancer Institute, University College London, London, UK.

Nasopharyngeal cancer (NPC), endemic in Southeast Asia, lacks effective diagnostic and therapeutic strategies. Even in high-income countries the 5-year survival rate for stage IV NPC is less than 40%. Here we report high somatostatin receptor 2 (SSTR2) expression in multiple clinical cohorts comprising 402 primary, locally recurrent and metastatic NPCs. We show that SSTR2 expression is induced by the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) via the NF-κB pathway. Using cell-based and preclinical rodent models, we demonstrate the therapeutic potential of SSTR2 targeting using a cytotoxic drug conjugate, PEN-221, which is found to be superior to FDA-approved SSTR2-binding cytostatic agents. Furthermore, we reveal significant correlation of SSTR expression with increased rates of survival and report in vivo uptake of the SSTR2-binding Ga-DOTA-peptide radioconjugate in PET-CT scanning in a clinical trial of NPC patients (NCT03670342). These findings reveal a key role in EBV-associated NPC for SSTR2 in infection, imaging, targeted therapy and survival.
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http://dx.doi.org/10.1038/s41467-020-20308-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785735PMC
January 2021

ACE2 localizes to the respiratory cilia and is not increased by ACE inhibitors or ARBs.

Nat Commun 2020 10 28;11(1):5453. Epub 2020 Oct 28.

Department of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, USA.

The coronavirus SARS-CoV-2 is the causative agent of the ongoing severe acute respiratory disease pandemic COVID-19. Tissue and cellular tropism is one key to understanding the pathogenesis of SARS-CoV-2. We investigate the expression and subcellular localization of the SARS-CoV-2 receptor, angiotensin-converting enzyme 2 (ACE2), within the upper (nasal) and lower (pulmonary) respiratory tracts of human donors using a diverse panel of banked tissues. Here, we report our discovery that the ACE2 receptor protein robustly localizes within the motile cilia of airway epithelial cells, which likely represents the initial or early subcellular site of SARS-CoV-2 viral entry during host respiratory transmission. We further determine whether ciliary ACE2 expression in the upper airway is influenced by patient demographics, clinical characteristics, comorbidities, or medication use, and show the first mechanistic evidence that the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) does not increase susceptibility to SARS-CoV-2 infection through enhancing the expression of ciliary ACE2 receptor. These findings are crucial to our understanding of the transmission of SARS-CoV-2 for prevention and control of this virulent pathogen.
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http://dx.doi.org/10.1038/s41467-020-19145-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595232PMC
October 2020

Outcomes in Treatment of Rhinosinusitis in the Setting of Medication Induced Immunosuppression.

Am J Rhinol Allergy 2021 Mar 3;35(2):221-225. Epub 2020 Aug 3.

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

Background: There is no data currently available to direct nuanced treatment for recurrent acute and chronic rhinosinusitis (RARS, CRS) in patients on daily, long term medications that suppress the immune system.

Objective: This study sought to evaluate the outcomes of different treatment pathways when treating immunosuppressed patients with chronic rhinosinusitis or recurrent acute rhinosinusitis.

Methods: A retrospective review of patients on immune suppressing medication presenting to a tertiary care center with RARS or CRS between the years 2014-2019 was completed. Patients were categorized into three groups based on treatment: medical management alone (MM), surgery after medical management (SAMM), or upfront surgery (US). Lund-Kennedy scores (LKS) and SNOT-22 scores were evaluated at baseline, 1 month, 3 months and 6 months from presentation.

Results: 68 patients met inclusion criteria, with no difference in demographics between groups. Patients who were treated with US and SAMM had significantly higher baseline LKS than those who were treated with MM alone (p = 0.050, p = 0.039). Once this difference was controlled for, there was no significant difference in overall change of LKS between the three groups over time. There was no significant disparity in baseline SNOT-22 scores between the three groups, but patients who underwent US had a significantly higher improvement in SNOT-22 from baseline compared to those undergoing MM alone (p = 0.013).

Conclusion: Patients experiencing chronic rhinosinusitis and recurrent acute rhinosinusitis who are taking immunosuppressive medication can significantly improve from both medical and surgical management, but upfront surgical management appears to result in greater disease resolution relative to medical management in those with CRS. More study is needed in the RARS patient population regarding upfront surgery versus medical management.
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http://dx.doi.org/10.1177/1945892420947932DOI Listing
March 2021

Robust ACE2 protein expression localizes to the motile cilia of the respiratory tract epithelia and is not increased by ACE inhibitors or angiotensin receptor blockers.

medRxiv 2020 May 12. Epub 2020 May 12.

Baxter Laboratory, Department of Microbiology & Immunology, Stanford University School of Medicine, Stanford, California, USA.

We investigated the expression and subcellular localization of the SARS-CoV-2 receptor, angiotensin-converting enzyme 2 (ACE2), within the upper (nasal) and lower (pulmonary) respiratory tracts of healthy human donors. We detected ACE2 protein expression within the cilia organelle of ciliated airway epithelial cells, which likely represents the initial or early subcellular site of SARS-CoV-2 viral entry during respiratory transmission. We further determined whether ACE2 expression in the cilia of upper respiratory cells was influenced by patient demographics, clinical characteristics, co-morbidities, or medication use, and found no evidence that the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) increases ACE2 protein expression.
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http://dx.doi.org/10.1101/2020.05.08.20092866DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273284PMC
May 2020

Application of holographic augmented reality for external approaches to the frontal sinus.

Int Forum Allergy Rhinol 2020 Jul 3;10(7):920-925. Epub 2020 May 3.

Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA.

Background: External approaches to the frontal sinus such as osteoplastic flaps are challenging because they require blind entry into the sinus, posing risks of injury to the brain or orbit. Intraoperative computed tomography (CT)-based navigation is the current standard for planning the approach, but still necessitates blind entry into the sinus. The aim of this work was to describe a novel technique for external approaches to the frontal sinus using a holographic augmented reality (AR) application.

Methods: Our team developed an AR system to create a 3-dimensional (3D) hologram of key anatomical structures, based on CT scans images. Using Magic Leap AR goggles for visualization, the frontal sinus hologram was aligned to the surface anatomy in 6 fresh cadaveric heads' anatomic boundaries, and the boundaries of the frontal sinus were demarcated based on the margins of the fused image. Trephinations and osteoplastic flap approaches were performed. The specimens were re-scanned to assess the accuracy of the osteotomy with respect to the actual frontal sinus perimeter.

Results: Registration and surgery were completed successfully in all specimens. Registration required an average of 2 minutes. The postprocedure CT showed a mean difference of 1.4 ± 4.1 mm between the contour of the osteotomy and the contour of the frontal sinus. One surgical complication (posterior table perforation) occurred (16%).

Conclusion: We describe proof of concept of a novel technique utilizing AR to enhance external approaches to the frontal sinus. Holographic AR-enhanced surgical navigation holds promise for enhanced visualization of target structures during surgical approaches to the sinuses.
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http://dx.doi.org/10.1002/alr.22546DOI Listing
July 2020

The Effect of Endoscopic Sinus Surgery on Eustachian Tube Dysfunction Symptoms.

Otolaryngol Head Neck Surg 2020 09 28;163(3):603-610. Epub 2020 Apr 28.

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

Objective: We assessed how eustachian tube dysfunction (ETD) changed with endoscopic sinus surgery (ESS) and identified factors associated with improvement.

Study Design: Retrospective chart review.

Setting: Academic center.

Subjects And Methods: Patients undergoing ESS for chronic rhinosinusitis with and without nasal polyposis (CRSwNP, CRSsNP) or recurrent acute rhinosinusitis (RARS) completed the Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. Included in analyses were demographics, comorbidities, Sinonasal Outcome Test 22 (SNOT-22), radiographic score, endoscopy score, procedure, and medication use. Regression analysis identified factors associated with improvement, defined as ΔETDQ-7 >3.5.

Results: In total, 302 patients were studied. ETD prevalence was 68% in CRSsNP, 48% in CRSwNP, and 88% in RARS. Patients with ETD had a mean baseline ETDQ-7 of 25.8 ± 8.0 and improved postoperatively at 2 weeks (19.9 ± 8.1, < .001), 6 weeks (17.8 ± 9.3, < .001), 3 months (16.8 ± 8.5, < .001), and 6 months (16.4 ± 7.9, < .001). At 6 months, ETD improved in 89% of patients with CRSsNP, 68% with CRSwNP, and 78% with RARS. On multivariate analysis, ETD improvement was associated with higher preoperative ETDQ-7 score (adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 1.04-1.22; = .030), higher preoperative SNOT-22 score (aOR, 1.02; 95% CI, 1.02-1.08; = .001), higher preoperative SNOT-22 ear subscore (aOR, 1.27; 95% CI, 1.02-1.65; = .034), posterior ethmoidectomy (aOR, 1.59; 95% CI, 1.22-4.92; = .025), and postoperative corticosteroid spray use (aOR, 1.57; 95% CI, 1.17-1.66; = .008).

Conclusion: ETD symptoms often improve following ESS. Factors associated with improvement include higher preoperative disease burden, posterior ethmoidectomy, and postoperative corticosteroid spray.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/0194599820917396DOI Listing
September 2020

In Reply: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic.

Neurosurgery 2020 08;87(2):E162-E163

Departments of Otolaryngology-Head & Neck Surgery and Neurosurgery Stanford University School of Medicine Stanford, California.

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http://dx.doi.org/10.1093/neuros/nyaa156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188177PMC
August 2020

Microbiotyping the Sinonasal Microbiome.

Front Cell Infect Microbiol 2020 8;10:137. Epub 2020 Apr 8.

Department of Otolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, SA, Australia.

This study offers a novel description of the sinonasal microbiome, through an unsupervised machine learning approach combining dimensionality reduction and clustering. We apply our method to the International Sinonasal Microbiome Study (ISMS) dataset of 410 sinus swab samples. We propose three main sinonasal "microbiotypes" or "states": the first is -dominated, the second is -dominated, and the third dominated by the other core genera of the sinonasal microbiome (, and ). The prevalence of the three microbiotypes studied did not differ between healthy and diseased sinuses, but differences in their distribution were evident based on geography. We also describe a potential reciprocal relationship between species and , suggesting that a certain microbial equilibrium between various players is reached in the sinuses. We validate our approach by applying it to a separate 16S rRNA gene sequence dataset of 97 sinus swabs from a different patient cohort. Sinonasal microbiotyping may prove useful in reducing the complexity of describing sinonasal microbiota. It may drive future studies aimed at modeling microbial interactions in the sinuses and in doing so may facilitate the development of a tailored patient-specific approach to the treatment of sinus disease in the future.
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http://dx.doi.org/10.3389/fcimb.2020.00137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156599PMC
April 2020

Letter: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic.

Neurosurgery 2020 07;87(1):E66-E67

Departments of Otolaryngology-Head & Neck Surgery and Neurosurgery Stanford University School of Medicine Stanford, California.

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http://dx.doi.org/10.1093/neuros/nyaa125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7184431PMC
July 2020

A multi-institutional review of outcomes in biopsy-proven chronic invasive fungal sinusitis.

Int Forum Allergy Rhinol 2020 06 13;10(6):738-747. Epub 2020 Apr 13.

Department of Otolaryngology, University of Washington, Seattle, WA.

Background: Chronic invasive fungal sinusitis (CIFS) is a rare, life-threatening infection of the nose and sinuses. This study aims to identify factors that impact survival in 1 of the largest cohorts to date.

Methods: Pathology records were reviewed for biopsy-proven CIFS from 3 tertiary academic institutions from 1995 to 2016. Variables were analyzed using log-rank survival analysis. Univariate Cox regression was performed at 1 and 12 months.

Results: Thirty-eight patients were included. Hematologic malignancy and diabetes were the most common underlying diseases (32% each). Aspergillus was the most common fungus (63%). Greater than 75% of the patients had an absolute neutrophil count (ANC) >1000 at the time of diagnosis. Overall survival at 1, 6, and 12 months was 89%, 68%, and 48%, respectively. In univariate analysis, factors associated with worse survival included: ANC <500 at 12 months (hazard ratio [HR] 4.8; p = 0.01), ANC <1000 at 12 months (HR 5.8; p = 0.001), and recent chemotherapy (HR 4; p = 0.01). The following factor was associated with improved survival in univariate analysis: ANC as a linear variable in the entire cohort (HR 0.7; p = 0.005).

Conclusion: We present a multi-institutional case-series of CIFS and long-term follow-up. ANC <1000 at time of diagnosis and recent chemotherapy (within 1 month of diagnosis) are associated with poorer survival, whereas a rising ANC >1000 is associated with improved survival at 12 months. Further prospective studies are needed to further define factors that affect outcomes.
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http://dx.doi.org/10.1002/alr.22547DOI Listing
June 2020

Indications and Outcomes for Patients With Limited Symptoms Undergoing Endoscopic Sinus Surgery.

Am J Rhinol Allergy 2020 Jul 13;34(4):502-507. Epub 2020 Mar 13.

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

Background: Previous research have suggested that chronic rhinosinusitis (CRS) patients with lower symptomatic scores, demonstrated by a 22-item Sinonasal Outcome Test (SNOT-22) score <20, may not achieve meaningful quality of life improvement following endoscopic sinus surgery (ESS). However, indications for ESS are continuing to be defined and many low SNOT-22 scoring patients still undergo elective surgery for CRS and other benign sinonasal pathologies. The outcomes for these patients have not been previously studied.

Objectives: We sought to evaluate surgical indications and outcomes for those patients with limited symptoms undergoing ESS.

Methods: We screened 2829 ESS procedures from 2010-2018 to identify patients with a preoperative SNOT-22 score <20. We reviewed disease characteristics, preoperative Lund-Mackay (LM) scores, and pre- and postoperative SNOT-22 scores in patients with at least 3 months' follow-up.

Results: Of all surgical ESS patients screened, 114 had low preoperative SNOT-22 scores (4.0%). Indications for these surgeries included CRS (50.0%), odontogenic sinus disease (11.4%), mucocele (10.5%), recurrent acute sinusitis (7.0%), fungal ball (5.3%), and silent sinus syndrome (4.4%). Specifically, among CRS patients, 45.6% had pulmonary comorbidities and/or systemic immunodeficiencies. Moreover, 100% of CRS patients with nasal polyps and 73.1% of CRS without polyps had LM scores >5. Patients with preoperative SNOT-22 scores between 15 and 19 achieved an average 6.5 point reduction ( < .001) postoperatively, whereas those with scores between 10 and 14 had a 5.4 point reduction ( < .001), and preoperative scores <9 resulted in no significant decrease in postoperative symptom scores ( = .98). Overall, there was a 3.3 point SNOT-22 reduction among all patients at 3 months postoperatively ( < .001).

Conclusion: Patients with limited sinonasal symptoms may benefit from surgical treatment despite asymptomatic clinical presentations. A case-by-case analysis of comorbidities or unique clinical features should inform surgical decision-making for patients with lower SNOT-22 scores.
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http://dx.doi.org/10.1177/1945892420912159DOI Listing
July 2020

The international sinonasal microbiome study: A multicentre, multinational characterization of sinonasal bacterial ecology.

Allergy 2020 08 30;75(8):2037-2049. Epub 2020 Mar 30.

Department of Otolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, SA, Australia.

The sinonasal microbiome remains poorly defined, with our current knowledge based on a few cohort studies whose findings are inconsistent. Furthermore, the variability of the sinus microbiome across geographical divides remains unexplored. We characterize the sinonasal microbiome and its geographical variations in both health and disease using 16S rRNA gene sequencing of 410 individuals from across the world. Although the sinus microbial ecology is highly variable between individuals, we identify a core microbiome comprised of Corynebacterium, Staphylococcus, Streptococcus, Haemophilus and Moraxella species in both healthy and chronic rhinosinusitis (CRS) cohorts. Corynebacterium (mean relative abundance = 44.02%) and Staphylococcus (mean relative abundance = 27.34%) appear particularly dominant in the majority of patients sampled. Amongst patients suffering from CRS with nasal polyps, a statistically significant reduction in relative abundance of Corynebacterium (40.29% vs 50.43%; P = .02) was identified. Despite some measured differences in microbiome composition and diversity between some of the participating centres in our cohort, these differences would not alter the general pattern of core organisms described. Nevertheless, atypical or unusual organisms reported in short-read amplicon sequencing studies and that are not part of the core microbiome should be interpreted with caution. The delineation of the sinonasal microbiome and standardized methodology described within our study will enable further characterization and translational application of the sinus microbiota.
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http://dx.doi.org/10.1111/all.14276DOI Listing
August 2020

Nasal Symptoms Following Laryngectomy: A Cross-sectional Analysis.

Am J Rhinol Allergy 2020 May 21;34(3):388-393. Epub 2020 Jan 21.

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

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http://dx.doi.org/10.1177/1945892420901631DOI Listing
May 2020

Effect of Omega-3 Supplementation in Patients With Smell Dysfunction Following Endoscopic Sellar and Parasellar Tumor Resection: A Multicenter Prospective Randomized Controlled Trial.

Neurosurgery 2020 08;87(2):E91-E98

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

Background: Endoscopic endonasal approaches pose the potential risk of olfactory loss. Loss of olfaction and potentially taste can be permanent and greatly affect patients' quality of life. Treatments for olfactory loss have had limited success. Omega-3 supplementation may be a therapeutic option with its effect on wound healing and nerve regeneration.

Objective: To evaluate the impact on olfaction in patients treated with omega-3 supplementation following endoscopic skull base tumor resection.

Methods: In this multi-institutional, prospective, randomized controlled trial, 110 patients with sellar or parasellar tumors undergoing endoscopic resection were randomized to nasal saline irrigations or nasal saline irrigations plus omega-3 supplementation. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and at 6 wk, 3 mo, and 6 mo postoperatively.

Results: Eighty-seven patients completed all 6 mo of follow-up (41 control arm, 46 omega-3 arm). At 6 wk postoperatively, 25% of patients in both groups experienced a clinically significant loss in olfaction. At 3 and 6 mo, patients receiving omega-3 demonstrated significantly less persistent olfactory loss compared to patients without supplementation (P = .02 and P = .01, respectively). After controlling for multiple confounding variables, omega-3 supplementation was found to be protective against olfactory loss (odds ratio [OR] 0.05, 95% CI 0.003-0.81, P = .03). Tumor functionality was a significant independent predictor for olfactory loss (OR 32.7, 95% CI 1.15-929.5, P = .04).

Conclusion: Omega-3 supplementation appears to be protective for the olfactory system during the healing period in patients who undergo endoscopic resection of sellar and parasellar masses.
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http://dx.doi.org/10.1093/neuros/nyz559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360874PMC
August 2020

Hemodynamic changes in patients undergoing office-based sinus procedures under local anesthesia.

Int Forum Allergy Rhinol 2020 01 5;10(1):114-120. Epub 2019 Nov 5.

Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA.

Background: The objective of this study is to characterize changes in hemodynamics, pain, and anxiety during office-based endoscopic sinus procedures performed under local anesthesia.

Methods: We conducted a prospective study of adults undergoing in-office endoscopic sinus procedures under local anesthesia. Patients with American Society of Anesthesiologists (ASA) Physical Status Classification System class 1 or 2 were included. Anesthesia was administered by topical 4% lidocaine/oxymetazoline and submucosal injection of 1% lidocaine/1:200,000 epinephrine. Vital signs and pain were measured at baseline, postinjection, and 5-minute intervals throughout the procedure. Anxiety levels were scored using the State-Trait Anxiety Inventory (STAI). Univariate and multivariate regression analyses were performed to identify factors significantly associated with changes in each hemodynamic metric.

Results: Twenty-five patients were studied. This cohort was 52% male, mean age of 57.8 ± 14.4 years, and Charlson Comorbidity Index (CCI) median of 2. Mean procedure duration was 25.0 ± 10.3 minutes. Mean maximal increase in systolic blood pressure (SBP) was 24.6 ± 17.8 mmHg from baseline. Mean maximal heart rate increase was 22.8 ± 10.8 beats per minute (bpm) from baseline. In multivariate regression analysis, when accounting for patient age, cardiac comorbidity, CCI, and ASA, older age was significantly associated with an increase of >20 mmHg in SBP (p = 0.043). Mean pain score during procedures was 1.5 ± 1.3 with a mean maximum of 4.0 ± 2.6. STAI anxiety scores did not change significantly from preprocedure to postprocedure (32.8 ± 11.6 to 31.0 ± 12.6, p = 0.46). No medical complications occurred.

Conclusion: Although patients appear to tolerate office procedures well, providers should recognize the potential for significant fluctuations in blood pressure during the procedure, especially in older patients.
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http://dx.doi.org/10.1002/alr.22460DOI Listing
January 2020

High-Efficiency, Selection-free Gene Repair in Airway Stem Cells from Cystic Fibrosis Patients Rescues CFTR Function in Differentiated Epithelia.

Cell Stem Cell 2020 02 12;26(2):161-171.e4. Epub 2019 Dec 12.

Department of Pediatrics, Stanford University, Stanford, CA 94304, USA. Electronic address:

Cystic fibrosis (CF) is a monogenic disorder caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. Mortality in CF patients is mostly due to respiratory sequelae. Challenges with gene delivery have limited attempts to treat CF using in vivo gene therapy, and low correction levels have hindered ex vivo gene therapy efforts. We have used Cas9 and adeno-associated virus 6 to correct the ΔF508 mutation in readily accessible upper-airway basal stem cells (UABCs) obtained from CF patients. On average, we achieved 30%-50% allelic correction in UABCs and bronchial epithelial cells (HBECs) from 10 CF patients and observed 20%-50% CFTR function relative to non-CF controls in differentiated epithelia. Furthermore, we successfully embedded the corrected UABCs on an FDA-approved porcine small intestinal submucosal membrane (pSIS), and they retained differentiation capacity. This study supports further development of genetically corrected autologous airway stem cell transplant as a treatment for CF.
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http://dx.doi.org/10.1016/j.stem.2019.11.002DOI Listing
February 2020

Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy.

Laryngoscope 2020 12 14;130(12):E736-E741. Epub 2019 Dec 14.

Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A.

Objectives/hypothesis: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS.

Study Design: Retrospective outcomes research.

Methods: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed.

Results: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P = .005).

Conclusions: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS.

Level Of Evidence: 2c Laryngoscope, 2019.
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http://dx.doi.org/10.1002/lary.28460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293548PMC
December 2020

Neutrophil Extracellular Traps Induce Tissue-Invasive Monocytes in Granulomatosis With Polyangiitis.

Front Immunol 2019 13;10:2617. Epub 2019 Nov 13.

Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.

Granulomatosis with polyangiitis (GPA) is a multi-organ vasculitic syndrome typically associated with neutrophil extracellular trap (NET) formation and aggressive tissue inflammation. Manifestations in head and neck (H&N) GPA include septal perforations, saddle-nose deformities, bony erosions of the orbital and sinus walls, middle ear damage and epiglottitis, indicative of bone, cartilage, and connective tissue destruction. Whether H&N-centric lesions engage disease pathways distinctive from the ischemic tissue damage in the lungs, kidneys, skin, and peripheral nerves is unknown. We have compared inflammatory responses triggered by neutrophilic NETs in patients with H&N GPA and systemic GPA (sGPA). Neutrophils and monocytes were isolated from the peripheral blood of patients with H&N GPA, sGPA, and age/gender matched healthy individuals. Neutrophil NETosis was induced. NETs were isolated and cocultured with monocytes. Gene induction was quantified by RT-PCR, protein upregulation by flow cytometry. Tissue invasiveness of monocytes was measured in a 3D collagen matrix system. Expression of MMP-9 in tissue-residing macrophages was assessed by immunohistochemistry in tissue biopsies. Neutrophils from H&N GPA patients showed more intense NETosis with higher frequencies of netting neutrophils ( < 0.001) and release of higher amounts of NETs ( < 0.001). Isolated NETs from H&N GPA functioned as an inducer of danger-associated molecular patterns in monocytes; specifically, alarmin S100A9. NET-induced upregulation of monocyte S100A9 required recognition of DNA. S100A9 release resulted in the induction of metalloproteinases, including MMP-9, and enabled monocytes to invade into extracellular matrix. Anti-MMP-9 treatment attenuated the tissue invasiveness of monocytes primed with NETs from H&N GPA patients. MMP-9-producing macrophages dominated the tissue infiltrates in naso-sinal biopsies from H&N GPA patients. Distinct disease patterns in GPA are associated with differences in NET formation and NET content. H&N GPA patients with midline cartilaginous and bony lesions are highly efficient in generating NETs. H&N GPA neutrophils trigger the induction of the alarmin S100A9, followed by production of MMP-9, endowing monocytes with tissue-invasive capabilities.
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http://dx.doi.org/10.3389/fimmu.2019.02617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874157PMC
November 2020

Clinical characteristics and prognostic factors of malignant tumors involving pterygopalatine fossa.

Head Neck 2020 02 4;42(2):281-288. Epub 2019 Nov 4.

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

Background: To identify the clinical characteristics and prognostic factors of malignancies involving the pterygopalatine fossa (PPF).

Methods: Fifty-seven patients who underwent curative surgery for malignant tumor involving PPF were reviewed.

Results: The rates for three-year local control (LC), five-year disease-free survival (DFS) and five-year overall survival (OS) were 55.4%, 34.5%, and 52.7%, respectively. Perineural invasion (PNI) of the maxillary nerve with facial numbness (symptomatic V2 PNI) (P = .04) and cranial involvement (P = .03) were predictors for poor OS. Symptomatic V2 PNI was also a significant predictor for poor LC (P = .05) and DFS (P = .03). Within the subgroup analysis of patients with pathologically confirmed V2 PNI, asymptomatic V2 PNI patients had significantly better LC (71.2% vs 31.8%, P = .05) and DFS (43.8% vs 17.3%, P = .05) compared to symptomatic patients.

Conclusion: Malignant tumors involving the PPF have diverse pathologies and a poor prognosis. Symptomatic V2 PNI may be an independent poor prognostic factor.
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http://dx.doi.org/10.1002/hed.26000DOI Listing
February 2020

The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: a double-blind randomized controlled study.

Int Forum Allergy Rhinol 2020 02 31;10(2):147-152. Epub 2019 Oct 31.

Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN.

Background: The objective of this study is to determine whether the infiltration of 1% lidocaine with 1:100,000 epinephrine in addition to topical application of 1:1000 epinephrine significantly improves surgical field grading scale score over topical 1:1000 epinephrine alone.

Methods: A prospective, double-blind, randomized, controlled study was performed of 40 patients undergoing bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Patients were enrolled and randomly assigned to receive infiltration with 1% lidocaine with 1:100,000 epinephrine on 1 side of the nasal cavity vs plain saline on the other side in preparation for ESS. Both groups received topical application of 1:1000 epinephrine. Surgical videos were recorded and Wormald surgical field grading scale was assigned by 2 blinded reviewers. The number of extra 1:1000 epinephrine pledgets used during the surgery, estimated blood loss, and surgical duration were also recorded.

Results: There were no statistically significant differences in Wormald surgical field grading scale, number of extra pledgets used, or estimated blood loss between the nasal cavity side infiltrated with 1% lidocaine with 1:100,000 epinephrine in comparison to infiltration with saline. The side infiltrated with 1% lidocaine with 1:100,000 epinephrine had a reduced operative time compared to the side infiltrated with saline (p = 0.002). There were no differences in postoperative bleeding from questionnaire completed by patient at the first postoperative visit.

Conclusion: Addition of infiltration of 1% lidocaine with epinephrine 1:100,000 to topical application of epinephrine 1:1000 for preparation of ESS does not significantly improve surgical field of view compared to topical epinephrine alone.
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http://dx.doi.org/10.1002/alr.22468DOI Listing
February 2020

Cryosurgical ablation for treatment of rhinitis: A prospective multicenter study.

Laryngoscope 2020 08 30;130(8):1877-1884. Epub 2019 Sep 30.

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.

Objective: To assess the efficacy and safety of cryoablation of the posterior nasal nerve (PNN) for treatment of chronic rhinitis.

Methods: This was a prospective single-arm trial of 98 adult patients at six U.S. centers with chronic allergic and nonallergic rhinitis. PNN cryoablation was performed in-office under local anesthesia using a handheld device. Patients discontinued use of intranasal ipratropium 3 days prior to treatment and throughout the study period. Reflective Total Nasal Symptom Score (rTNSS) was measured at pretreatment baseline and posttreatment at 1 month, 3 months, 6 months, and 9 months. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was completed at pretreatment and 3 months posttreatment. Adverse effects and postprocedure medication usage were recorded.

Results: Ninety-eight procedures (100%) were successfully completed. rTNSS significantly improved over pretreatment baseline (6.1 ± 1.9) at 1 month (2.9 ± 1.9, P < 0.001), 3 months (3.0 ± 2.3, P < 0.001), 6 months (3.0 ± 2.1, P < 0.001), and 9 months (3.0 ± 2.4, P < 0.001) postprocedure. Nasal congestion and rhinorrhea subscores improved significantly at all time points (P < 0.001). Both allergic and nonallergic rhinitis subcohorts showed improvement (P < 0.001), with a comparable degree of improvement between groups. RQLQ significantly improved over pretreatment baseline (3.0 ± 1.0) at 3 months (1.5 ± 1.0, P < 0.001), and all RQLQ subdomains demonstrated improvement. Of 54 patients using intranasal medication at baseline, 19 (35.2%) were able to discontinue use. Twenty-nine adverse effects were reported, including headache, epistaxis, and sinusitis.

Conclusion: Cryoablation of the PNN for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life.

Level Of Evidence: 4 Laryngoscope, 130: 1877-1884, 2020.
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http://dx.doi.org/10.1002/lary.28301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384004PMC
August 2020

ICAR: endoscopic skull-base surgery.

Int Forum Allergy Rhinol 2019 07;9(S3):S145-S365

University of Pittsburgh, Pittsburgh, PA.

Background: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

Methods: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

Results: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

Conclusion: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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http://dx.doi.org/10.1002/alr.22326DOI Listing
July 2019

Workforce analysis of practicing rhinologists in the united states.

Laryngoscope 2020 05 27;130(5):1116-1121. Epub 2019 Jun 27.

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

Objectives: The objective of this study is to analyze the current rhinology workforce in the United States in terms of demographics, fellowship training, and regional distribution.

Methods: The American Rhinologic Society (ARS) member database was queried for workplace zip code, age, gender, and fellowship training of practicing U.S. rhinologists through 2017. The San Francisco Match data were examined for rhinology fellowships from 2006 through 2017. Each rhinologist was assigned to a specific hospital referral region (HRR) determined by the Dartmouth Healthcare Atlas to assess geographic distribution and market density.

Results: There were 296 ARS members self-identifying as rhinologists. Of those, 69.2% were fellowship-trained (FTR). The median age of FTRs and non-FTRs were 41 and 54 years, respectively (P < 0.001). Eighty percent of FTRs were male compared to 85.7% non-FTRs. Given the recent growth of rhinology fellowships, the number of FTRs is currently expanding at approximately 16% per year. HRRs with the most rhinologists were Los Angeles, Boston, and Manhattan, all with 14. Approximately 100 million people live in HRRs without a practicing rhinologist. A wide variation in rhinologist density was observed, ranging from 133,047 to 3,636,809 people per rhinologist, with a median of 747,864.

Conclusion: There may be a need for rhinologists in select parts of the country. Whereas the ARS database is likely an underestimation of the growing workforce, under current training rates we could pass the ideal number of U.S. rhinologists within 5 years.

Level Of Evidence: NA Laryngoscope, 130:1116-1121, 2020.
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http://dx.doi.org/10.1002/lary.28157DOI Listing
May 2020

Role of inferior turbinate reduction in the quality of life of patients undergoing endoscopic sinus surgery for chronic rhinosinusitis.

Int Forum Allergy Rhinol 2019 08 20;9(8):926-933. Epub 2019 Jun 20.

Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA.

Background: The impact on quality of life (QoL) of bilateral inferior turbinate reduction (BITR) performed in the setting of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) has been a point of controversy. The aim of this study was to determine whether addition of BITR to ESS is associated with improved QoL when compared with ESS alone.

Methods: This study presented findings a multi-institutional, retrospective analysis of a prospective open cohort of patients electing ESS for failed medical management of CRS. QoL parameters were compared between patients who underwent ESS alone vs those who underwent ESS with BITR.

Results: A total of 571 patients with CRS who elected to undergo ESS were identified. Sixty-one of these patients also underwent concurrent BITR, whereas 510 patients underwent ESS without BITR. Mean length of follow-up was 15.1 months. Comparison between baseline and last postoperative QoL, olfaction, and endoscopic scores revealed significant improvement in both groups. Overall, BITR surgery was not significantly associated with clinically significant incremental improvement in QoL in either the polyp or non-polyp group. Nevertheless, statistically significant improvement was noted for the nasal congestion/blockage symptom in polyp patients (p = 0.006) and in primary surgery patients (p = 0.027) who underwent BITR.

Conclusion: BITR in the setting of ESS for CRS is not associated with significant incremental improvement in overall QoL vs ESS alone. However, BITR in polyp and primary surgery patients undergoing ESS appears to offer a significant incremental improvement in nasal congestion/blockage symptoms compared with ESS alone. Future studies are warranted to better corroborate these findings.
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http://dx.doi.org/10.1002/alr.22356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687546PMC
August 2019

Transnasal endoscopic approach for pediatric skull base lesions: a case series.

J Neurosurg Pediatr 2019 Jun 14:1-12. Epub 2019 Jun 14.

1Department of Neurosurgery and.

Objective: Transnasal endoscopic transsphenoidal approaches constitute an essential technique for the resection of skull base tumors in adults. However, in the pediatric population, sellar and suprasellar lesions have historically been treated by craniotomy. Transnasal endoscopic approaches are less invasive and thus may be preferable to craniotomy, especially in children. In this case series, the authors present their institutional experience with transnasal endoscopic transsphenoidal approaches for pediatric skull base tumors.

Methods: The authors retrospectively reviewed pediatric patients (age ≤ 18 years) who had undergone transnasal endoscopic transsphenoidal approaches for either biopsy or resection of sellar or suprasellar lesions between 2007 and 2016. All operations were performed jointly by a team of pediatric neurosurgeons and skull base otolaryngologists, except for 8 cases performed by one neurosurgeon.

Results: The series included 42 patients between 4 and 18 years old (average 12.5 years) who underwent 51 operations. Headache (45%), visual symptoms (69%), and symptoms related to hormonal abnormalities (71%) were the predominant presenting symptoms. Improvement in preoperative symptoms was seen in 92% of cases. Most patients had craniopharyngiomas (n = 16), followed by pituitary adenomas (n = 12), Rathke cleft cysts (n = 4), germinomas (n = 4), chordomas (n = 2), and other lesion subtypes (n = 4). Lesions ranged from 0.3 to 6.2 cm (median 2.5 cm) in their greatest dimension. Gross-total resection was primarily performed (63% of cases), with 5 subsequent recurrences. Nasoseptal flaps were used in 47% of cases, fat grafts in 37%, and lumbar drains in 47%. CSF space was entered intraoperatively in 15 cases, and postoperative CSF was observed only in lesions with suprasellar extension. There were 8 cases of new hormonal deficits and 3 cases of new cranial nerve deficits. Length of hospital stay ranged from 1 to 61 days (median 5 days). Patients were clinically followed up for a median of 46 months (range 1-120 months), accompanied by a median radiological follow-up period of 45 months (range 3.8-120 months). Most patients (76%) were offered adjuvant therapy.

Conclusions: In this single-institution report of the transnasal endoscopic transsphenoidal approach, the authors demonstrated that this technique is generally safe and effective for different types of pediatric skull base lesions. Favorable effects of surgery were sustained during a follow-up period of 4 years. Further refinement in technology will allow for more widespread use in the pediatric population.
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http://dx.doi.org/10.3171/2019.4.PEDS18693DOI Listing
June 2019

Outcomes of sinonasal inverted papilloma resection by surgical approach: an updated systematic review and meta-analysis.

Int Forum Allergy Rhinol 2019 06 12;9(6):573-581. Epub 2019 Feb 12.

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

Background: Selecting the optimal surgical approach for resection of sinonasal inverted papilloma (SIP) remains a challenge, with endoscopic, external, and combined approaches being utilized. This systematic review was conducted as an update to a 2006 systematic review to determine the preferred surgical approach for tumor control.

Methods: The study protocol was developed a priori following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. Data were collected and outcomes were analyzed according to surgical approach and sites of tumor involvement.

Results: A total of 96 papers and 4134 SIP patients were included. The overall recurrence rate was 12.80% (322/2515) for the endoscopic approach group, 16.58% (182/1098) for the external approach group, and 12.60% (65/516) for the combined approach group. Meta-analysis by random effects model showed that the summarized risk ratio (RR) of recurrence was 0.61 (95% confidence interval [CI], 0.44 to 0.85, p = 0.003), I = 37.95% for the endoscopic vs external approach; 0.98 (95% CI, 0.69 to 1.39, p = 0.901), I = 9.06% for the endoscopic vs combined approach; 1.61 (95% CI, 1.06 to 2.43, p = 0.025), I = 0.00% for the external vs combined approach. After adjusting for publication bias, the adjusted RRs were 0.66 (p = 0.014) for endoscopic vs external; 0.99 (p = 0.955) for endoscopic vs combined; and 1.33 (p = 0.224) for external vs combined.

Conclusion: An enlarging and maturing body of literature continues to indicate that endoscopic approaches result in significantly lower recurrence rates than open approaches for surgical resection of SIP.
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http://dx.doi.org/10.1002/alr.22305DOI Listing
June 2019

Microcurrent technology for rapid relief of sinus pain: a randomized, placebo-controlled, double-blinded clinical trial.

Int Forum Allergy Rhinol 2019 04 22;9(4):352-356. Epub 2019 Jan 22.

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

Background: Transcutaneous electrical nerve stimulation has proven to be effective in alleviating chronic pain from facial myalgias. We evaluated the efficacy of a novel handheld microcurrent-emitting device in short-term, office-based treatment of patients with sinus pain. This device, which is U.S. Food and Drug Administration (FDA)-cleared, detects and treats regions corresponding to nerve fibers.

Methods: Randomized, double-blinded, placebo-controlled trial. Seventy-one participants with facial pain attributed to self-reported nasal/sinus disease were recruited from a tertiary rhinologic practice and the surrounding community and randomly assigned to either office-based use of an active (n = 38) or placebo (n = 33) microcurrent emitter. The study device was repetitively applied by each patient to the bilateral periorbital areas for 5 minutes. A visual analogue scale (VAS) for pain severity was administered before, and 10 minutes after, treatment.

Results: Active microcurrent-treated patients had a reduction in mean pain score from 5.63 pretreatment to 3.97 posttreatment (mean difference, 1.66; 95% confidence interval [CI], 1.20 to 2.12). Patients using the sham device also reported sinus pain reductions (mean difference, 0.91; 95% CI, 0.61 to 1.21). However, the active device demonstrated a significantly greater reduction in pain compared to sham (0.75-point difference, p = 0.007). Notably, 23.7% of patients using the active device had a reduction of 3 or more points by VAS compared to 0% of sham device patients (p = 0.003). One minor occurrence of transient facial skin erythema was noted.

Conclusion: This trial suggests that treatment of rhinologic facial pain using this noninvasive microcurrent device is safe and effective in providing rapid relief of nasal/sinus pain. Additional studies with longer term follow-up are warranted.
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http://dx.doi.org/10.1002/alr.22280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590214PMC
April 2019

Topical Corticosteroid Pretreatment Mitigates Cellular Damage After Caustic Injury to the Nasal Upper Airway Epithelium.

Am J Rhinol Allergy 2019 May 14;33(3):277-285. Epub 2019 Jan 14.

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

Background: Topical corticosteroids are currently employed to reduce established airway inflammation; their prophylactic use might help limit cellular damage against harmful stimuli.

Objectives: To determine the effects of a prophylactic topical application of budesonide (BD) on an in vivo nasal epithelium injury model induced by trichloroacetic acid (TCA).

Methods: C57Bl/6 mice were exposed to intranasal TCA topical application. Three groups received topical intranasal BD, saline solution, or no intervention prior to a single topical exposure to TCA. Controls were not exposed to TCA. Whole nasal cavity coronal sections were analyzed at 1, 3, and 6 days postinjury at tissue and cellular levels using histopathological analysis, immunofluorescent staining, and fresh tissue RNA microarray analysis.

Results: Prophylactic topical corticosteroid exposure protected the nasal epithelium from acute damage, maintaining epithelial thickness and cell survival. Six days following TCA exposure, epithelial and cellular changes were less pronounced on the BD-treated group compared to all exposure groups. The microarray analysis was used to evaluate the gene transcripts in all treatment groups. Ciliary tip protein, Sentan, and submucosal protein S100b were identified as potential factors in epithelial airway protection; immunofluorescent staining corroborated their presence and location within the respiratory epithelium.

Conclusion: Topical corticosteroid treatment to the nasal epithelium can mitigate several of the early deleterious effects of acute epithelial damage in experimental airway injuries caused by TCA. These findings suggest a novel, direct cytoprotective effect of corticosteroids on the nasal epithelium, and the potential of expanding the use of prophylactic periprocedural topical corticosteroids for respiratory epithelial tissues.
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http://dx.doi.org/10.1177/1945892418823305DOI Listing
May 2019