Publications by authors named "William C Yao"

35 Publications

Transorbital-transsinus resection of sinonasal malignancy with extraconal orbital extension.

Int Forum Allergy Rhinol 2021 Jul 14. Epub 2021 Jul 14.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA.

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http://dx.doi.org/10.1002/alr.22859DOI Listing
July 2021

Contour Map Point Distribution and Surgeon Experience Level Affect Accuracy of Surgical Navigation in a Pilot Study.

Ann Otol Rhinol Laryngol 2021 Jun 13:34894211005982. Epub 2021 Jun 13.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.

Background: Reliable use of surgical navigation depends upon the registration process. The gold standard is paired-point registration with bone-anchored fiducials, but contour-map registration is more practical. Surgeons may employ variable contour maps and less experienced team members often perform this critical step. The impact of these practices on target registration error (TRE) is not well-studied.

Methods: A dry lab set-up consisting of a navigation system (Fusion ENT, Medtronic, Jacksonville, FL) and a sinus phantom with 2 mm radiopaque spheres in the sphenoid and ethmoid regions was developed. A CT (0.625 mm slice thickness) was obtained. Registration was performed with a contour-based protocol. Accuracy was determined using the software's distance measurement tool. Registration was performed with narrow-field (NF; forehead points medial to the mid-pupillary line) and wide field (WF; entire forehead) contour maps. An experienced rhinologist and a resident surgeon performed each registration in triplicate and TRE at the sphenoid and ethmoid markers was measured in triplicate.

Results: WF mapping had a lower TRE than NF (1.09 mm [95% Confidence Interval (CI) 0.96-1.22] vs 1.68 mm [95% CI 1.50-1.86]). The experienced surgeon had a lower TRE compared to the resident (1.21 mm [95% CI 1.08-1.34] vs 1.54 mm [95% CI 1.35-1.74]).

Conclusions: In this navigation model, wide field mapping offers better accuracy than narrow-field mapping, and an experienced surgeon seemed to achieve better accuracy than a resident surgeon. These observations have potential implications for the use of this technology in the operating room.
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http://dx.doi.org/10.1177/00034894211005982DOI Listing
June 2021

Revisiting the controversy: The role of fungi in chronic rhinosinusitis.

Int Forum Allergy Rhinol 2021 Jun 2. Epub 2021 Jun 2.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

In the last two decades, the development of culture-independent genomic techniques has facilitated an increased appreciation of the microbiota-immunity interactions and their role in a multitude of chronic inflammatory diseases such as chronic rhinosinusitis (CRS), asthma, inflammatory bowel disease and dermatitis. While the pathologic role of bacteria in chronic inflammatory diseases is generally accepted, the understanding of the role of fungi remains controversial. Chronic rhinosinusitis, specifically the phenotype linked to nasal polyps, represents a spectrum of chronic inflammatory diseases typically characterized by a type 2 immune response. Studies on the microbiota within sinus cavities from healthy and diseased patients have focused on the bacterial community, mainly highlighting the loss of diversity associated with sinus inflammation. Within the various CRS with nasal polyps (CRSwNP) phenotypes, allergic fungal rhinosinusitis presents an opportunity to investigate the role of fungi in chronic type 2 immune responses as well as the antifungal immune pathways designed to prevent invasive fungal diseases. In this review, we examine the spectrum of fungi-associated sinus diseases highlighting the interaction between fungal species and host immune status on disease presentation. With a focus on fungi and type 2 immune response, we highlight the current knowledge and its limitations of the sinus mycobiota along with cellular interactions and activated molecular pathways linked to fungi.
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http://dx.doi.org/10.1002/alr.22826DOI Listing
June 2021

N95 respirator reuse, decontamination methods, and microbial burden: A randomized controlled trial.

Am J Otolaryngol 2021 Mar 31;42(5):103017. Epub 2021 Mar 31.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, Houston, TX, USA; Center for Immunology and Autoimmune Diseases, Institute of Molecular Medicine, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA. Electronic address:

Purpose: To evaluate the effectiveness and ease of N95 respirator decontamination methods in a clinic setting and to identify the extent of microbial colonization on respirators associated with reuse.

Methods: In a prospective fashion, N95 respirators (n = 15) were randomized to a decontamination process (time, dry heat, or ultraviolet C light [UVC]) in outpatient clinics. Each respirator was re-used up to 5 separate clinic sessions. Swabs on each respirator for SARS-CoV-2, bacteria, and fungi were obtained before clinic, after clinic and post-treatment. Mask integrity was checked after each treatment (n = 68). Statistical analyses were performed to determine factors for positive samples.

Results: All three decontamination processes reduced bacteria counts similarly. On multivariate mixed model analysis, there were an additional 8.1 colonies of bacteria (95% CI 5.7 to 10.5; p < 0.01) on the inside compared to the outside surface of the respirators. Treatment resulted in a decrease of bacterial load by 8.6 colonies (95% CI -11.6 to -5.5; p < 0.01). Although no decontamination treatment affected the respirator filtration efficiency, heat treatments were associated with the breakdown of thermoplastic elastomer straps. Contamination with fungal and SARS-CoV-2 viral particles were minimal to non-existent.

Conclusions: Time, heat and UVC all reduced bacterial load on reused N95 respirators. Fungal contamination was minimal. Heat could permanently damage some elastic straps making the respirators nonfunctional. Given its effectiveness against microbes, lack of damage to re-treated respirators and logistical ease, UVC represents an optimal decontamination method for individual N95 respirators when reuse is necessary.
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http://dx.doi.org/10.1016/j.amjoto.2021.103017DOI Listing
March 2021

The role of CT and endoscopy in the evaluation of patients referred for intranasal Cryoablation.

Am J Otolaryngol 2021 Jul-Aug;42(4):102971. Epub 2021 Feb 17.

Department of Otorhinolaryngology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States of America.

Background: Cryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an office-based procedure for chronic rhinitis (CR). Standardized preoperative evaluation, specifically the role of computed tomography (CT) and nasal endoscopy, has yet to be defined. We report a series of patients who underwent CT and endoscopy as part of CR work-up in patients referred for CA.

Objective: Highlight the importance of both nasal endoscopy and CT scan in the evaluation of CR given significant overlap of symptoms and common occurrence of related sinonasal conditions.

Methods: Retrospective analysis of all patients referred to a single tertiary rhinology practice for CA was performed.

Results: Fifteen patients were sent for CA by medical allergists. Five patients were deemed CA candidates, and 1 patient received only medical CR treatment. Four patients had evidence of incomplete prior sinus surgery and/or continued chronic rhinosinusitis on endoscopic exam. These 4 patients received a combination of medical and surgical management with either complete resolution or improvement in CR symptoms. In 3 patients, CT confirmed chronic rhinosinusitis that was not apparent on endoscopy, and received a combination of medical and surgical management with symptom improvement. In the last two patients, final diagnoses were nasal valve collapse and recurrent acute rhinosinusitis.

Conclusions: Referrals for CA are becoming more common and the optimal preoperative work up remains unclear. In this limited retrospective review, 67% of patients had diagnoses other than CR and thus were not deemed candidates for CA. Both CT and endoscopy are complementary to a detailed history and physical examination and can aid in CA candidate selection.
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http://dx.doi.org/10.1016/j.amjoto.2021.102971DOI Listing
February 2021

Characterizing the complexity of frontal endoscopic sinus surgery: a multi-institutional, prospective, observational trial.

Int Forum Allergy Rhinol 2021 May 4;11(5):941-945. Epub 2020 Dec 4.

Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT.

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http://dx.doi.org/10.1002/alr.22746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062301PMC
May 2021

Sniffin' Sticks to Measure Olfactory Function and Recovery Following Bilateral Superior Turbinate Resection as Part of Endoscopic Transsphenoidal Approach.

Ann Otol Rhinol Laryngol 2021 Jun 21;130(6):636-642. Epub 2020 Oct 21.

Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, TX, USA.

Background: Extended endoscopic transsphenoidal (EET) approaches can include complete resection of both superior turbinate (ST) for wider exposure. Moreover, ST resection has been associated with postoperative olfactory impairment.

Objective: We sought to determine the impact of bilateral ST resection on olfaction during a transsphenoidal approach.

Method: A prospective observational study was conducted on 29 patients undergoing endoscopic skull base surgery sparing the olfactory tracts at a tertiary academic center. Olfactory function was measured with Sniffin' Sticks at the preoperative visit, 2-weeks and 6 to 8 weeks postoperatively. All components: odor threshold (OT), odor discrimination (OD), odor identification (OI) and composite scores (TDI = OT+OD+OI) were evaluated.

Result: Study was completed in 15 patients with 14 excluded due to a variety of reasons. At 2 weeks, a significant decrease was noted in composite scores (32.3 ± 5.4 vs. 23.8 ± 5.8,  < .05) and OT (7.7 vs. 3.2,  < .05). There was a significant increase in olfactory scores between post-op weeks 2 and 6 to 8 weeks in TDI (23.8 vs. 31.4,  < .05) as well as in OT (3.2 vs. 7.6,  < .05), OD (9.4 vs. 11.1,  < .05), and OI (11.1 vs. 12.7,  < .05). No significant difference was found between TDI (32.3 ± 5.4 vs. 31.4 ± 5.1), OT (7.7 vs. 7.6), OD (11.4 vs. 11.1) and OI (13.2 vs. 12.7) from preoperative and 6-8 weeks postoperative visits.

Conclusion: Patients undergoing bilateral ST resection during EET procedures experience transient hyposmia postoperatively. However, the olfactory function normalizes to preoperative levels at 6 to 8 weeks. The resection of the bilateral superior turbinate does not appear to decrease olfactory function.
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http://dx.doi.org/10.1177/0003489420965621DOI Listing
June 2021

Double-blinded randomized prospective trial of intranasal capsaicin treatment for nonallergic rhinitis.

Int Forum Allergy Rhinol 2021 Jan 7;11(1):24-30. Epub 2020 Jul 7.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX.

Background: Nonallergic rhinitis (NAR) is currently a diagnosis of exclusion with an unclear pathophysiologic mechanism and limited treatment options. In patients diagnosed with NAR based on symptoms, negative skin testing and positive optical rhinometry (ORM), the study's objective was to evaluate the therapeutic action of intranasal capsaicin in the management of rhinitic symptoms and the effect on ORM readings.

Methods: Patients with a history of NAR underwent screening by a diagnostic intranasal capsaicin challenge with ORM and skin-prick testing. Twenty-two NAR patients were enrolled and randomized to either treatment with 0.1mM capsaicin (n = 11) or placebo (n = 11). Treatment consisted of 5 consecutive intranasal applications separated by 1 hour with follow-up at 4 and 12 weeks. At each visit, subjects underwent intranasal capsaicin challenge with ORM reading and a visual analog scale scoring of rhinitis symptoms.

Results: Treatment with intranasal capsaicin resulted in a median change with improvement in total symptom score (TSS) of -5 from baseline vs an increase of 2 with placebo at 4 weeks, which remained significantly different between the groups at 12 weeks (p = 0.03). At 12 weeks posttreatment, 60% of the intervention group vs 80% of placebo-treated patients still met objective criteria for NAR by ORM.

Conclusion: Using ORM in the objective diagnosis of NAR, this trial showed that intranasal 0.1mM capsaicin not only improved rhinitic symptoms but also objectively reduced nasal reactivity and nasal congestion with a 40% responder rate at 12 weeks as noted by ORM.
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http://dx.doi.org/10.1002/alr.22637DOI Listing
January 2021

Full Remission of Long-Term Premenstrual Dysphoric Disorder-Like Symptoms Following Resection of a Pituitary Adenoma: Case Report.

Am J Case Rep 2020 Aug 8;21:e922797. Epub 2020 Aug 8.

The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth®), McGovern Medical School, Houston, TX, USA.

BACKGROUND Few case reports exist in the literature of patients with pituitary adenoma presenting with premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). Complete remission of persistent PMDD symptoms after surgical removal of a pituitary lesion has not been reported. CASE REPORT We report a case of a 44-year-old woman with childbearing potential who underwent transsphenoidal surgery (TSS) in December 2017 to remove a non-functioning pituitary adenoma. The surgery resulted in full remission of her PMDD symptoms. The patient's hormone levels remained stable before and after the TSS procedure. During 28 months of follow-up, the woman has been asymptomatic for periods of 6 consecutive months or longer without taking antidepressants. Given the patient's current condition, a durable remission from PMDD is anticipated. CONCLUSIONS We believe that refractory PMS/PMDD associated with pituitary lesions is under-diagnosed and under reported. As demonstrated in this case, surgical intervention for a sellar mass has the potential to be effective or even curative for patients with PMS/PMDD. We recommend that physicians consider magnetic resonance imaging of the brain in patients with PMS/PMDD.
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http://dx.doi.org/10.12659/AJCR.922797DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440754PMC
August 2020

Aerosol generation with common rhinologic devices: cadaveric study conducted in a surgical suite.

Int Forum Allergy Rhinol 2020 11 19;10(11):1261-1263. Epub 2020 Aug 19.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX.

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http://dx.doi.org/10.1002/alr.22679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436219PMC
November 2020

High-Efficiency Particulate Air Filters in the Era of COVID-19: Function and Efficacy.

Otolaryngol Head Neck Surg 2020 12 14;163(6):1153-1155. Epub 2020 Jul 14.

Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.

Aerosol-generating procedures in the office represent a major concern for health care-associated infection of patients and health care providers by SARS-CoV-2, the causative agent for coronavirus disease 2019 (COVID-19). Although the Centers for Disease Control and Prevention has not yet provided any recommendations for the use of portable air purifiers, air purifiers with high-efficiency particulate air (HEPA) filters have been discussed as an adjunctive means for decontamination of SARS-CoV-2 aerosols in health care settings. This commentary discusses HEPA filter mechanisms of action, decontamination time based on efficiency and flow rate, theoretical application to SARS-CoV-2, and limitations. HEPA filter functionality and prior guidance from the Centers for Disease Control and Prevention for SARS-CoV-1 suggest theoretical efficacy for HEPA filters to decontaminate airborne SARS-CoV-2, although direct studies for SARS-CoV-2 have not been performed. Any portable HEPA purifier utilization for SARS-CoV-2 should be considered an adjunctive infection control measure and undertaken with knowledge of HEPA filter functionality and limitations in mind.
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http://dx.doi.org/10.1177/0194599820941838DOI Listing
December 2020

Image-Guided Surgery and Intraoperative Imaging in Rhinology: Clinical Update and Current State of the Art.

Ear Nose Throat J 2020 May 26:145561320928202. Epub 2020 May 26.

Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA.

Introduction: Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes.

Objectives: Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies.

Methods: English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advances.

Conclusions: As image guidance and intraoperative imaging systems have advanced, their applications in sinus and skull base surgery have expanded. Both technologies offer invaluable real-time feedback on the status and progress of surgery, and thus may help to improve the completeness of surgery and overall outcomes. Recent advances such as augmented and virtual reality offer a window into the future of IGS. Future advancements should aim to enhance the surgeon's operative experience by improving user satisfaction and ultimately lead to better surgical results.
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http://dx.doi.org/10.1177/0145561320928202DOI Listing
May 2020

PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis.

Otolaryngol Head Neck Surg 2020 01 12;162(1):142-147. Epub 2019 Nov 12.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Objective: Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire-9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22).

Study Design: Retrospective chart review.

Setting: Tertiary rhinology practice.

Subjects And Methods: During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22.

Results: Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson's coefficient of 0.632 ( < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score ≥10).

Conclusion: Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.
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http://dx.doi.org/10.1177/0194599819886852DOI Listing
January 2020

Analysis of Sinonasal Microbiota in Exacerbations of Chronic Rhinosinusitis Subgroups.

OTO Open 2019 Jul-Sep;3(3):2473974X19875100. Epub 2019 Sep 17.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Objective: Microbiome analyses now allow precise determination of the sinus microbiota of patients with exacerbations of chronic rhinosinusitis (CRS). The aim of this report is to describe the sinus microbiota of acute exacerbations in CRS clinical subgroups (with nasal polyps [CRSwNP], without nasal polyps [CRSsNP], and allergic fungal rhinosinusitis [AFRS]).

Study Design: Retrospective chart review.

Setting: Tertiary rhinology practice.

Subjects And Methods: A retrospective review was performed of all patients whose sinus microbiota were assayed via a commercially available microbiome technology during an acute CRS exacerbation during the 2-year period ending December 31, 2016. All samples were sinus aspirates collected under endoscopic visualization in clinic.

Results: Samples from a total of 134 patients (65 CRSsNP, 55 CRSwNP, and 14 AFRS) were reviewed. The observed richness (number of taxa >2% relative abundance) ranged between 1 and 11 taxa, with an average of 3 taxa per specimen. The most common bacteria in all groups were spp (including ), spp, spp, and spp. had an increased prevalence in CRSsNP and AFRS as compared with CRSwNP. Otherwise, the sinus microbiota were markedly similar among all 3 clinical subgroups.

Conclusions: Many bacterial types are identified during acute CRS exacerbation according to DNA-based detection techniques. Bacterial richness was remarkably low in all samples. Few differences in the patterns among clinical subgroups were observed. Further investigation is warranted to determine the clinical significance of these observations and their role in current clinical algorithms.
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http://dx.doi.org/10.1177/2473974X19875100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6749786PMC
September 2019

The Potential of High-Throughput DNA Sequencing of the Paranasal Sinus Microbiome in Diagnosing Odontogenic Sinusitis.

Otolaryngol Head Neck Surg 2019 12 6;161(6):1043-1047. Epub 2019 Aug 6.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Objective: High-throughput DNA sequencing of the paranasal sinus microbiome has potential in the diagnosis and treatment of sinusitis. The objective of this study is to evaluate the use of high-throughput DNA sequencing to diagnose sinusitis of odontogenic origin.

Study Design: Case series with chart review.

Setting: Single tertiary care academic medical center.

Subjects And Methods: A chart review was performed of DNA sequencing results from the sinus aspirates obtained under endoscopic visualization in 142 patients with sinusitis. The identification of any potentially pathogenic bacteria associated with oral flora in a sample was classified as a positive result for sinusitis of odontogenic etiology. The sensitivity, specificity, and predictive values of using high-throughput DNA sequencing to diagnose sinusitis of odontogenic etiology were determined, with the patient's computed tomography sinus scan as the reference standard. On computed tomography scans, an odontogenic source was determined by the presence of a periapical lucency perforating the schneiderian membrane.

Results: Seven of the 142 patients enrolled in this study had an odontogenic source based on computed tomography scans. Relative to this reference standard, high-throughput DNA sequencing produced a sensitivity of 85.7% (95% CI, 42.1%-99.6%), a specificity of 81.5% (95% CI, 73.9%-87.6%), a positive predictive value of 19.4% (95% CI, 13.1%-27.7%), and a negative predictive value of 99.1% (95% CI, 94.7%-99.9%).

Conclusion: This study supports the use of high-throughput DNA sequencing in supplementing other methods of investigation for identifying an odontogenic etiology of sinusitis.
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http://dx.doi.org/10.1177/0194599819866692DOI Listing
December 2019

Aspergillus fumigatus induction of IL-33 expression in chronic rhinosinusitis is PAR2-dependent.

Laryngoscope 2019 10 11;129(10):2230-2235. Epub 2019 Apr 11.

Department of Otolaryngology-Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, U.S.A.

Objective: In the pathophysiology of chronic rhinosinusitis with nasal polyps (CRSwNP), Aspergillus fumigatus (A. fumigatus) can upregulate IL-33 from human sinonasal epithelial cells (SNECs), which then activates innate lymphoid cells causing release of IL-13, an important driver of allergic inflammation. However, the mechanism by which A. fumigatus mediates the induction of IL-33 expression remains to be elucidated. The objectives of this study were to determine the specific fungal component(s) and the receptor responsible for mediating the A. fumigatus induced increase in IL-33 expression in SNECs from patients with CRSwNP.

Methods: SNECs from CRSwNP patients were cultured and stimulated with various fungal components in the absence or presence of 4-(2-Aminoethyl)benzenesulfonyl fluoride hydrochloride, an irreversible serine protease inhibitor, or GB83, a reversible protease activated receptor 2 (PAR2) inhibitor. IL-33 expression was evaluated using quantitative real-time polymerase chain reaction (qRT-PCR). PAR2 expression was examined in inflamed mucosa from nonatopic control and CRSwNP patients.

Results: Elevation of IL-33 expression in primary SNECs was found in response to fungal protease but not fungal cell wall components. PAR2 expression was elevated in inflamed mucosa from CRSwNP patients in comparison to controls. The A. fumigatus fungal protease-mediated elevation in IL-33 expression by human SNECs was serine protease- and PAR2-dependent.

Conclusion: These data suggest that serine protease activity of A. fumigatus is capable of inducing IL-33 expression in CRSwNP SNECs via PAR2, a potential therapeutic target in the treatment of CRSwNP.

Level Of Evidence: NA Laryngoscope, 129:2230-2235, 2019.
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http://dx.doi.org/10.1002/lary.28000DOI Listing
October 2019

Office-Based Sinus Surgery.

Otolaryngol Clin North Am 2019 Jun 22;52(3):473-483. Epub 2019 Mar 22.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA. Electronic address:

Office-based rhinologic procedures have seen a dramatic rise in incidence over the last decade. It is crucial to select appropriate patients and understand which pathologies may be amenable to in-office procedures. It behooves the otolaryngologist to be familiar with the array of technologic advances that are expanding the limits of office-based rhinology and to have a solid understanding of the technical nuances of using these technologies in the clinic. This article highlights the issues associated with some of the more common office-based sinus procedures, and provides practical information on set-up and reimbursement.
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http://dx.doi.org/10.1016/j.otc.2019.02.003DOI Listing
June 2019

Contributions of Innate Lymphoid Cells in Chronic Rhinosinusitis.

Curr Allergy Asthma Rep 2019 03 22;19(5):28. Epub 2019 Mar 22.

Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, 77030, USA.

Purpose Of Review: To review innate lymphoid cells (ILCs) and their role in chronic rhinosinusitis (CRS).

Recent Findings: The immune system consists of the innate and adaptive response. Until the recognition of ILCs, chronic inflammatory diseases were characterized by cytokines linked only to T helper cells. However, these immune responses are now described more broadly to include contributions from both the innate and adaptive immunity. In CRS, focus had been on ILC2s in CRS with nasal polyps. These studies also highlight the importance of epithelial cell-derived cytokines in coordinating these responses. In addition to indirect crosstalk via cytokines, ILCs and T helper cells can utilize the OX40/OX40 ligand and major histocompatibility complex class II pathways to directly interact and coordinate responses. In addition to T helper cells, ILCs contribute to the inflammatory response associated with CRS. The understanding of these cells along with pathways that activate and perpetuate these cells leads to new potential therapeutic targets for CRS treatment.
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http://dx.doi.org/10.1007/s11882-019-0861-7DOI Listing
March 2019

Nonpharmacological Relaxation Technology for Office-Based Rhinologic Procedures.

ORL J Otorhinolaryngol Relat Spec 2019;81(1):48-54. Epub 2019 Mar 5.

Department of Otorhinolaryngology - Head and Neck Surgery, John P. and Kathrine G. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Background: Office-based rhinologic procedures are increasingly performed to control costs and enhance patient convenience. Adequate management of pain and anxiety is essential for the technical performance of these procedures, in addition to ensuring patient comfort. Pharmacologic agents are often used to manage anxiety and pain. Nonpharmacological adjuncts may be useful for achieving these effects without oral opioids and benzodiazepines.

Methods: Charts of patients who underwent office-based rhinologic procedures with the NuCalm system (Solace Lifesciences, Inc., Wilmonton, DE, USA) in combination with local anesthesia were reviewed. NuCalm is a proprietary system that combines cranial electrotherapy stimulation, neuroacoustic software, light-blocking lenses, and topical γ--aminobutyric acid. Patients rated their pain and anxiety before, during, and after the procedure.

Results: Twenty-five patients underwent office procedures using the NuCalm system. Preoperative anxiety (2.00) was significantly higher than postoperative anxiety (1.25) according to patient reporting on a 5-point scale (p = 0.005). Preoperative pain (1.83) was not significantly different from intraoperative (2.54) and postoperative pain (2.04, p = 0.054).

Conclusions: A variety of office-based rhinologic procedures are technically feasible and can be performed with adequate patient comfort without the use of oral drugs. Adjuncts to pharmacologic agents may enhance pain control and anxiety management and improve patient tolerance of these procedures.
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http://dx.doi.org/10.1159/000488323DOI Listing
May 2020

The intraoperative accuracy of maxillary balloon dilation: a blinded trial.

Int Forum Allergy Rhinol 2019 05 10;9(5):452-457. Epub 2019 Jan 10.

Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX.

Background: Balloon sinus dilation (BSD) is a commonly performed sinus procedure in the United States. Several cadaveric studies have evaluated BSD accuracy and the maxillary sinus has consistently been shown to be the most challenging to cannulate. We designed an independent study to evaluate the intraoperative accuracy of maxillary sinus BSD.

Methods: A prospective, single-blinded trial evaluating the accuracy of maxillary sinus BSD was performed using 2 commercially available BSD systems (guidewire- and probe-based systems) randomly assigned to patients undergoing endoscopic surgery for chronic rhinosinusitus without nasal polyps (CRSsNP) or a skullbase approach in patients without sinus disease. All patients underwent maxillary BSD followed by uncinectomy to reveal dilation of the natural maxillary sinus ostia. The recorded procedures were reviewed by 3 fellowship-trained rhinologists from different institutions blinded to the BSD system utilized. The primary endpoint compared accuracy of maxillary BSD attempts. The secondary endpoint compared accuracy between the 2 systems.

Results: Twenty-nine maxillary BSD procedures were performed in 18 patients (age range, 20-79 years; mean, 51 years) without nasal polyposis undergoing maxillary antrostomy as part of a more extensive procedure. BSD was successful in 18 of 29 (62%) attempts and unsuccessful in 9 of 29 (31%) attempts, with statistically "almost perfect" interrater agreement (kappa = 0.86). There was no statistical difference between the 2 BSD systems (p = 0.81).

Conclusion: Maxillary BSD appeared to be less accurate in living patients when compared with findings from previously published cadaver studies. There were no differences in accuracy between the probe- and guidewire-based systems. This is the first non-industry-sponsored study evaluating maxillary sinus BSD in living patients. Further studies are needed to investigate the clinical implications of our findings.
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http://dx.doi.org/10.1002/alr.22286DOI Listing
May 2019

International assessment of inter- and intrarater reliability of the International Frontal Sinus Anatomy Classification system.

Int Forum Allergy Rhinol 2019 01 14;9(1):39-45. Epub 2018 Sep 14.

Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, TX.

Background: Inconsistencies in the nomenclature of structures of the frontal sinus have impeded the development of a validated "reference standard" classification system that surgeons can reliably agree upon. The International Frontal Sinus Anatomy Classification (IFAC) system was developed as a consensus document, based on expert opinion, attempting to address this issue. The purposes of this study are to: establish the reliability of the IFAC as a tool for classifying cells in the frontal recess among an international group of rhinologists; and improve communication and teaching of frontal endoscopic sinus surgery (ESS).

Methods: Forty-two computed tomography (CT) scans, each with a marked frontal cell, were reviewed by 15 international fellowship-trained rhinologists. Each marked cell was classified into 1 of 7 categories described in the IFAC, on 2 occasions separated by 2 weeks. Inter- and intrarater reliability were evaluated using Light's kappa (κ), the interclass correlation coefficient (ICC), and simple proportion of agreement.

Results: Interrater reliability showed pairwise κ values ranging from 0.7248 to 1.0, with a mean of 0.9162 (SD, 0.0537). The ICC was 0.98. Intrarater reliability showed κ values ranging from 0.8613 to 1.0, with a mean of 0.9407 (SD, 0.0376). The within-rater ICC was 0.98.

Conclusion: Among a diverse sample of rhinologists (raters), there was substantial to almost perfect agreement between raters, and among individual raters at different timepoints. The IFAC is a reliable tool for classification of cells in the frontal sinus. Further outcome studies are still needed to determine the validity of the IFAC.
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http://dx.doi.org/10.1002/alr.22200DOI Listing
January 2019

Use of Autologous Fat Grafts for the Endoscopic Reconstruction of Skull Base Defects: Indications, Outcomes, and Complications.

Am J Rhinol Allergy 2018 Jul 7;32(4):310-317. Epub 2018 May 7.

2 Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas.

Background The use of abdominal free fat is a traditional surgical method for the repair and reconstruction of the anterior skull base. Our objective is to assess the outcomes associated with the autologous fat graft to endoscopically repair anterior skull base defects at a single tertiary care center. Methods All patients, who underwent endoscopic skull base repair utilizing abdominal free fat from September 2009 to June 2016, were included for retrospective chart review. Evaluated outcome measurements included (1) the successful closure of preoperative and intraoperative cerebrospinal fluid (CSF) leaks and (2) complications at both donor and recipient graft sites during the postoperative periods. Four representative clinical cases have additionally been selected to highlight the common indications for which the fat graft may be effective in skull base reconstruction. Results Of the 27 patients who were identified for inclusion in this review, 25 (92.6%) demonstrated successful repair of preoperative or intraoperative CSF leaks following primary skull base repair. Two patients developed recurrent CSF leaks occurring about 1 week after their primary closures, and a secondary closure rate of 96.3% was achieved with use of fat grafts. Other complications included seroma and hematoma formation at the abdominal donor sites, each occurring in 1 patient. Conclusions The use of autologous fat remains a viable option for grafting material during endoscopic skull base reconstruction. Despite the wide variety of closure techniques in skull base surgery, autologous fat provides safe and easily accessible material to repair CSF leaks.
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http://dx.doi.org/10.1177/1945892418773637DOI Listing
July 2018

Cutting-edge endonasal surgical approaches to thyroid ophthalmopathy.

Laryngoscope Investig Otolaryngol 2018 Apr 26;3(2):100-104. Epub 2018 Feb 26.

Department of Otorhinolaryngology-Head & Neck Surgery McGovern Medical School, University of Texas Health Science Center at Houston Texas U.S.A.

Objective: Thyroid orbitopathy is a poorly understood extrathyroidal manifestation of Graves' disease that can cause disfiguring proptosis and vision loss. Orbital decompression surgery for Graves' orbitopathy (GO) can address both cosmetic and visual sequelae of this autoimmune condition. Endonasal endoscopic orbital decompression provides unmatched visualization and access to inferomedial orbital wall and orbital apex. This review examines the state of the art approaches employed in endonasal endoscopic orbital decompression for GO.

Methods: Review of literature evaluating novel surgical maneuvers for GO.

Results: Studies examining the efficacy of endonasal endoscopic orbital decompression are heterogenous and retrospective in design; however, they reveal this approach to be a safe and effective technique in the management of GO.

Conclusion: Subtle variations in endoscopic techniques significantly affect postsurgical outcomes and can be tailored to the specific clinical indication in GO making endonasal endoscopic decompression the most versatile approach available.

Level Of Evidence: NA.
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http://dx.doi.org/10.1002/lio2.143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915818PMC
April 2018

Management of odontogenic cysts by endonasal endoscopic techniques: A systematic review and case series.

Am J Rhinol Allergy 2018 Jan;32(1):40-45

From the Department of Otorhinolaryngology-Head and Neck Surgery, John P. and Kathrine G. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas.

Background: Odontogenic cysts and tumors of the maxilla may be amendable to management by endonasal endoscopic techniques, which may reduce the morbidity associated with open procedures and avoid difficult reconstruction.

Objective: To perform a systematic review that evaluates the feasibility and outcomes of endoscopic techniques in the management of different odontogenic cysts. A case series of our experience with these minimally invasive techniques was assembled for insight into the technical aspects of these procedures.

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to identify English-language studies that reported the use of endoscopic techniques in the management of odontogenic cysts. Several medical literature data bases were searched for all occurrences in the title or abstract of the terms "odontogenic" and "endoscopic" between January 1, 1950, and October 1, 2016. Publications were evaluated for the technique used, histopathology, complications, recurrences, and the follow-up period. A case series of patients who presented to a tertiary rhinology clinic and who underwent treatment of odontogenic cysts by an endoscopic technique was included.

Results: A systematic review identified 16 case reports or series that described the use of endoscopic techniques for the treatment of odontogenic cysts, including 45 total patients. Histopathologies encountered were radicular (n = 16) and dentigerous cysts (n = 10), and keratocystic odontogenic tumor (n = 12). There were no reported recurrences or major complications for a mean follow-up of 29 months. A case series of patients in our institution identified seven patients without recurrence for a mean follow-up of 10 months.

Conclusion: Endonasal endoscopic treatment of various odontogenic cysts are described in the literature and are associated with effective treatment of these lesions for an average follow-up period of >2 years. These techniques have the potential to reduce morbidity associated with the resection of these lesions, although comparative studies would better define specific indications.
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http://dx.doi.org/10.2500/ajra.2018.32.4492DOI Listing
January 2018

Eustachian tube dysfunction symptoms in patients treated in a tertiary rhinology clinic.

Int Forum Allergy Rhinol 2017 12 16;7(12):1135-1139. Epub 2017 Nov 16.

Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX.

Background: Ear symptoms are common among patients presenting to a rhinology clinic. Validated inventories are available for patient quality-of-life in sinonasal disease and Eustachian tube dysfunction (ETD). This study sought to determine the extent of ETD symptoms, using validated metrics, in a large population of patients presenting to a tertiary rhinology clinic.

Methods: Seven-item Eustachian Tube Dysfunction Questionnaires (ETDQ-7) and 22-item Sino-Nasal Outcome Tests (SNOT-22) were prospectively collected from 492 patients treated in a tertiary rhinology clinic. Patient diagnoses were retrospectively determined from the medical record. Correlation between reported SNOT-22 and ETDQ-7 scores were analyzed, in addition to the number of patients meeting the criterion score for ETD.

Results: A total of 213 patients reported mean ETDQ-7 scores >2.1, consistent with a diagnosis of ETD. Overall SNOT-22 scores were strongly correlated with ETDQ-7 scores (r = 0.679, p < 0.001). The SNOT-22 ear subdomain was very strongly correlated with the ETDQ-7 score (r = 0.847, p < 0.001), while there was a moderate correlation with the SNOT-22 rhinologic subdomain (r = 0.486, p < 0.001). Patients with allergic fungal sinusitis had decreased ETDQ-7 scores compared to patients with other rhinologic diagnoses (p = 0.010).

Conclusion: Symptoms of ETD are common in patients treated in a rhinology clinic, with 43.3% of patients reporting symptom scores consistent with a formal diagnosis of ETD. Increased SNOT-22 scores are correlated with increased ETDQ-7 scores, even when only the SNOT-22 rhinologic subdomain is considered. Patients presenting for treatment of rhinologic symptoms likely have an increased prevalence of otologic symptoms and ETD.
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http://dx.doi.org/10.1002/alr.22030DOI Listing
December 2017

Role of intraoperative ropivacaine in adult post-tonsillectomy pain control: A randomized controlled trial.

Ear Nose Throat J 2017 Apr-May;96(4-5):E39-E43

Department of Otorhinolaryngology-Head and Neck Surgery, University of Texas McGovern Medical School, 6431 Fannin St., MSB 5.036, Houston, TX 77030, USA.

We sought to evaluate the efficacy of ropivacaine in post-tonsillectomy pain management in adults and evaluate the timing of intraoperative ropivacaine administration for this purpose. A prospective, double-blinded, randomized, controlled trial with a paired design was performed in 25 consecutive adults undergoing tonsillectomy. To date, no studies examining the efficacy of local anesthetics in post-tonsillectomy pain control have used a paired design to account for the variability in pain difference between individuals. Patients were prerandomized into those receiving tonsillar fossa injections before or after the tonsillectomy. All surgeries were performed by the senior author. The tonsil on 1 side was injected with saline and the tonsil on the other side with ropivacaine. Patient responses were obtained via written questionnaire. Three of 25 patients were excluded from the study. Sixteen of 22 patients had lateralization of pain to 1 side during recovery. No statistically significant difference in pain control was observed between ropivacaine and normal saline. Local anesthetic decreased pain in 7 of 22 patients, and increased pain was experienced on the side with local anesthetic in 9 of 22 patients. Six of 22 patients had no difference in pain from one side to the other. The time to equalization of pain based on laterality was 8.8 and 6.8 days, respectively, in the patients injected before or immediately after the tonsillectomy. Administration of the local anesthetic ropivacaine does not affect post-tonsillectomy pain. Moreover, timing of injection does not affect postoperative pain. We recommend against the use of intraoperative ropivacaine for pain control in patients undergoing tonsillectomy.
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March 2018

Sinocutaneous Fistula Formation After Forehead Recontouring Surgery for Transgender Patients.

J Craniofac Surg 2017 May;28(3):e274-e277

*Department of Otolaryngology, Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA †Department of Otorhinolaryngology, Head and Neck Surgery, University of Texas McGovern Medical School, Houston, TX.

Forehead recontouring is a common part of facial feminization surgery. The procedure, which alters the shape and structure of the frontal bone, is regarded as safe and well tolerated by patients. The occurrence of delayed complications, however, is much less understood. The authors describe a patient involving the development of a sinocutaneous fistula as a delayed complication of forehead recontouring surgery. The clinical presentation and management of this patient are discussed. As facial feminization surgery expands as a cosmetic option for patients who desire more feminine facial features, practitioners should recognize the potential risk of sinonasal complications associated with forehead recontouring surgery.
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http://dx.doi.org/10.1097/SCS.0000000000003524DOI Listing
May 2017

Nasal mucosal melanosis may act as a harbinger of melanoma: A case report.

Allergy Rhinol (Providence) 2016 Jan;7(3):164-167

Background: The progression from a benign pigmented lesion on the skin to cutaneous melanoma is better understood, and it could be presumed that a similar progression occurs with mucosal lesions. However, to our knowledge, there has never been documentation of melanosis transforming into melanoma over time.

Objective: To describe a transformation of a mucosal melanosis into melanoma.

Methods: A 53-year-old man with diffuse melanosis of the nasal cavity underwent surgical resection.

Results: Pathology revealed melanocytic hyperplasia without evidence of melanoma. The patient was serially examined, with excisions for new areas of melanosis. The pathology progressed to severely atypical melanocytic proliferation and melanoma in situ over a 4-year period.

Conclusion: Nasal melanosis may be a precancerous lesion and may transform into melanoma. All melanosis should be biopsied with close endoscopic observation. Lesions with dysplasia or atypia should be excised due to potential transformation to melanoma.
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http://dx.doi.org/10.2500/ar.2016.7.0174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244274PMC
January 2016

Orbital Decompression in the Endoscopic Age: The Modified Inferomedial Orbital Strut.

Otolaryngol Head Neck Surg 2016 05 1;154(5):963-9. Epub 2016 Mar 1.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA.

Objective: Postoperative diplopia occurs in up to 45% of patients following orbital decompression for exophthalmos associated with Graves' orbitopathy. We sought to describe outcomes of our balanced orbital decompression strategy that includes the preservation of a modified inferomedial orbital strut (mIOS).

Study Design: Case series with chart review.

Setting: Academic medical center.

Subjects And Methods: A total of 115 consecutive orbital decompressions were performed on 73 patients (42 bilateral) with Graves' orbitopathy. All patients underwent (1) a balanced decompression technique incorporating an endoscopic medial and external lateral decompression and (2) a mIOS technique with preservation of the anterior half of the inferomedial orbital strut. A periorbital periosteal (orbital) sling was utilized in patients (n = 54) without threatened vision loss, proptosis >28 mm, or periorbital disruption to prevent prolapse of the medial rectus muscle.

Results: Utilization of the mIOS technique with or without a sling did not adversely affect the reduction in proptosis (5.1 mm with sling vs 5.0 mm without sling; P = .85).The incidence of new-onset postoperative diplopia was 17% (n = 6). The sling was not associated with postoperative diplopia (odds ratio = 0.54, 95% confidence interval: 0.08-3.40, P = .51), while it was associated with resolution of preexisting diplopia (odds ratio = 6.67, 95% confidence interval: 1.06-42.06, P = .04). No intraoperative complications occurred, and no patients suffered a decrement in visual acuity.

Conclusion: Balanced orbital decompression utilizing a mIOS in patients with Graves' orbitopathy provides a safe and effective reduction in proptosis with a low rate of new-onset diplopia as compared with historical values. Utilization of an orbital sling may be beneficial in reducing postoperative diplopia in select patients.
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http://dx.doi.org/10.1177/0194599816630722DOI Listing
May 2016

Endoscopic management of orbital tumors.

Curr Opin Otolaryngol Head Neck Surg 2016 Feb;24(1):57-62

aDepartment of Otorhinolaryngology - Head and Neck Surgery, University of Texas Medical School at Houston, Houston, Texas bDepartment of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

Purpose Of Review: Orbital tumors have been classically approached via external incision. The introduction of endoscopic surgery has revolutionized the management of sinus and skull base disorder. Similarly, endoscopic techniques have been increasingly utilized to access intraorbital tumors located in the medial and inferior orbit with excellent outcomes. The history of the procedure, surgical anatomy of the orbit, patient selection, surgical planning, and the surgical techniques are discussed in this article.

Recent Findings: Although the endoscopic management of orbital tumors is still in its infancy, it has already demonstrated enhanced access to the posterior orbit and orbital apex with decreased morbidity relative to external approaches.

Summary: A multidisciplinary team approach, including an oculoplastic surgeon, is an essential component for the surgical planning and management. As the cumulative surgical experience increases, the indications for this approach will likely continue to expand.
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http://dx.doi.org/10.1097/MOO.0000000000000215DOI Listing
February 2016
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