Led by nose to science, surgery

- By Tracie White

Norbert von der Groeben nose

At 40 years old, Jayaker Nayak, a rhinologist, is among an increasingly rare class of scientist-surgeons who divide their time between conducting research in their labs and treating patients in clinics and hospitals.

The Roto-Rooter man is slowly snaking his way through some majorly clogged pipes, a man on a mission. His goal, as usual, is the sweet sound of a clogged pipe draining.

“It’s very easy to get lost in here,” said Jayakar Nayak, MD, PhD, sitting down next to his 30-year-old chronic sinusitis patient who is lying anesthetized on an operating table in the outpatient surgery center at Stanford Hospital & Clinics. On a video screen in front of him is a real-time image of the insides of the patient’s diseased sinuses, clogged up so badly she has barely been able to breathe through her nose since the age of 12. A second screen shows a detailed sinus CAT scan that can track where Nayak is within the sinus passage, almost like GPS for the nose.

Well into their second hour of a four-hour surgery, Nayak and his surgical team are manipulating microsurgical tools inserted through the woman’s nostrils down natural drainage pathways into the anatomical maze that makes up the complex world of the sinuses. Cool, huh? Right now, they are searching for the frontal sinus situated just above the eyes, which forms the hard part of the forehead. This is where the serious clogging caused by years of sinusitis has occurred. And this is why his patient, Marianne (who asked that her last name not be used), has battled headaches, endless drippiness, stuffiness, pounding facial pressure, and finally a complete loss of a sense of smell, for years.

“I do my best to correct the plumbing so the sinuses work normally, so that they drain normally,” said Nayak, a rhinologist recruited a year and a half ago to the Stanford Sinus Center for his skills as not only a surgeon, but as a scientist committed to curing the diseases of the nose. He is sometimes referred to as a “wizard of snot.”

“I’m kind of a Roto-Rooter man for the nose, so to speak,” he said.

“The operating theater is a unique place, and I do love it in here,” he said, working in the darkened operating room during endoscopy, as he offers words of encouragement to the surgical resident whose gloved hands are carefully maneuvering the endoscopic tools — the micro scissors, teeny tiny vacuum, miniature camera — deeper into the sinus caverns. “It’s fascinating to operate in sensitive areas, like the back sphenoid sinus, where the carotid artery can be seen beating right there in your view.  While I love surgery, and it can bring a lot of benefit to patients, I also love the research lab too. Without breakthroughs in the lab, one can only help a single patient at a time like Marianne.”

Rare breed

Nayak, assistant professor of otolaryngology, is a rare breed, in more ways than one. The snot doc is part of a shrinking group of surgeons at academic universities who also run a basic science laboratory. His research focuses on the regeneration of the mucosal lining of the nose and also nasal immune responses, each of which could someday help chronic sinusitis sufferers like Marianne, the woman lying on the surgical bed undergoing her fifth nasal surgery (her first under Nayak’s care). He’s among four newly appointed surgeon-scientists to join the Department of Otolaryngology.

On Monday, Tuesday and Wednesday, Nayak is in his laboratory across campus, peering through microscopes at the diseased tissue that he snips and vacuums out of his patients’ sinuses in the operating room on Fridays. On Thursdays, he’s in the Stanford Sinus Center clinic — as always dressed in scrubs; it’s a messy job. He’s clearing out clogged up noses, breaking up nasal fungus balls, getting sneezed on and asking patients questions like: “Do you get a lot of discharge when you blow your nose?”

Jayakar Nayak

Jayakar Nayak

Stanford is doing its best to encourage and support surgeon-scientists and other physicians-scientists. “We’re lucky to have him,” said Peter Hwang, MD, professor of otolaryngology and director of the Stanford Sinus Center, who, together with Robert Jackler, MD, professor and chair of the Department of Otolaryngology, went searching for that rare breed of talented surgeon who knows his way around the research bench.  “We strongly believe that the great breakthroughs in treating chronic illnesses such as sinusitis will depend on the successful application of basic science research findings toward practical patient care,” Hwang added. “Unfortunately, qualified applicants who excel in both the lab and the operating room are rare.”

As science and medicine have grown ever more complex, the years of education needed to be either a scientist or a surgeon has stretched ever longer, making it even more demanding for one person to keep on the cutting edge of both worlds. At the same time, surgeon-scientists have the added demand that they must operate routinely, often weekly, to keep their surgical skills sharp. Nayak has 20 years of post-high school education. He’s 40 years old and completed his training two years ago.

“It’s very special to have someone who is both a serious scientist and a very successful surgeon,” said Jackler. “Surgeons understand disease in their areas and can help to guide our research efforts down lines relevant to curing human disease.

“It’s not easy doing both,” he added. “But we see surgeon-scientists as key. Our goal is to create an environment in which surgeons sustain career-long productivity in research, not just have a brief burst of creativity for a few years at the start. This translational linkage is essential.”

Center's growth

The Stanford Sinus Center, which brought Nayak into the fold, has over 5,000 patient visits per year. It treats patients with chronic sinusitis, nasal polyposis, fungal sinusitis, nasal obstruction and tumors of the nasal cavity and anterior skull base. This summer Nayak and neurosurgeon Stefan Mindea, MD, performed one of the first successful nasal endoscopic spinal surgeries on the West Coast, removing a degenerative tumor from the upper spine through the nose.

The center also runs the research arm of the program focusing on the clinical and basic science aspects of sinus disease. Current studies include researching the optimization of sinus wound healing and the evaluation of surgical outcomes in patients with chronic rhino sinusitis.

It’s the perfect place for Nayak, who discovered his love of science as an undergraduate at the University of Pennsylvania and then his love of surgery as an MD/PhD student and surgery resident at the University of Pittsburgh. He moved to Stanford with his wife, a fellow in anesthesiology at Stanford, in 2009 because he could do both at the Sinus Center.

“Working both in the clinic and the operating room is the only way to appreciate the subtle complexities of the disease,” Nayak said. In his lab, Nayak’s primary focus of research is the regeneration of the mucosal lining of the nose. He’s studying how the mucosal lining first forms in the developing nasal cavity and how it develops. The hope is that by understanding the basic epithelial cell biology of the dysfunction, surgeons can someday reline the nose of chronic sinusitis sufferers whose tissue lining has been destroyed by severe infection.

Patients with chronic sinusitis are Nayak’s “bread and butter” in surgery as he calls it. The majority of his patients have the disease. And that’s where he focuses his research. The suffering that he sees in patient after patient in his weekly clinic motivates the direction of his work in the lab. Chronic sinusitis is an insidious disease that lingers for years with no known cause or cure. Patients with this condition have sinuses that are unable to drain well due to the inflammation of the narrow drainage pathways. As a result, nasal secretions become trapped in the sinuses and become infected. Unless you’ve suffered from the disease, you don’t know what misery it can cause, patients say. “They try everything,” Nayak said. Nasal sprays, medications, quick-fix surgeries until they finally make their way to Nayak whose expertise in the operating room can successfully clear out years of scar tissue and inflammation.

And, for now, until there are further breakthroughs in the research lab, Nayak relies on his tools in the operating room to do his best to relieve their suffering. “We have some of the best toys in  medicine,” said Nayak, smiling earnestly. (Another reason he went into this field.)  He’s referring to the endoscopic surgical tools that are actually small fiber optic telescopes that allow almost all of his surgeries to be performed through the nostrils, without skin incisions. The microscopic tools can blast their way through years of clogged sinuses, traversing the sinus passageways like a plumbers snake, gingerly cutting up bony tumors and overgrown polyps, then sucking them out with surprisingly gentle microscopic vacuum.

Which is exactly what the surgical team does to the insides of Marianne’s sinuses. Led by Nayak, the team has cut and vacuumed their way through the clogged up passageways, snipping away inflamed, infected tissues and forests of overgrown polyps. They’ve together vacuumed out pus, infection, scar tissue, all the while carefully winding their way through the complicated labyrinth of the sinuses to avoid the brain and optic nerve fibers just a few millimeters away from the tips of their tools.

“All right, excellent,” said Nayak with delight. “Channel’s now all clear!” He’s scrubbed in, watching the video screen. It’s painstakingly detailed work that sometimes lasts well into Friday afternoon.

On Monday, the dark operating room filled with computer monitors and high-tech gadgetry, will be replaced with the bright lights of the research lab, filled with microscopes and dissection hoods, and the detail-oriented fellows and lab assistants bent on uncovering the mysteries of disease.

For now, Marianne is just grateful she was one of the patients that Nayak could help in the operating room. “It’s been years of just torture,” she said in an interview a month after surgery. She described how she had been through four previous quick-fix surgeries prior to coming to Stanford to see Nayak that had left her disillusioned. “Your head just feels heavy, heavy, heavy. You’re always, always congested, stuffed up.”

So far, the most recent surgery has left her more than optimistic. “I can breathe through my nose,” she said. “It’s a blessing.” And for the first time in years, she can smell again. “Dr. Nayak thinks it’s a really good sign,” Marianne said. “I think it’s a blessing.”

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu.

2023 ISSUE 3

Exploring ways AI is applied to health care