December 2021 Newsletter
December 17, 2021
The Otology and Neurotology Division welcomes a new member, Dr. Stankovic
Her translational research aims to improve diagnosis and treatment of hearing loss; recent press releases: Antihypertension drug may help patients with noncancerous brain tumors affecting hearing, COVID-19 can infect the inner ear, and HRRP-funded investigators develop miniature imaging probe to visualize cellular pathology in the inner ear.
December 17, 2021
Novel treatments in the management of Zenker’s diverticulum
Our division continues to experience outstanding results and high patient satisfaction using a technique we developed to remove Zenker’s diverticuli entirely transorally. Patient dissatisfaction with the 20% recurrence rates associated with transoral stapling led us to develop a method for endscopic resection of the criccopharyngeus muscle and diverticulum, with endoscopic manual suture closure. This technique has allowed us to combine the advantages and safety of endoscopic surgery with long term outcomes associated with traditional open approaches. We continue to offer this as the mainstay of treatment for patients interested in a long-term endoscopic approach to their swallowing difficulties. More information about our results can be found in our publications:
Junlapan A, Boonipat T, Sung CK, Damrose EJ. Endoscopic treatment of Zenker’s Diverticulum- the modified transoral approach. J Vis Surg 2020;6: 42 https://jovs.amegroups.com/article/view/42321/html
and Junlapan A, Abu-Ghanem S, Sung CK, Damrose EJ. Outcomes in modified transoral resection of diverticula for Zenker's diverticulum. Eur Arch Otorhinolaryngol. 2019 May;276(5):1423-1429.
December 17, 2021
Understanding the cause of idiopathic subglottic stenosis
Our division is currently involved in understanding the mechanism underpinning idiopathic subglottic stenosis, a progressive and refractory scarring disorder of the larynx which principally affects middle-aged women. We recently identified the presence of an estrogen receptor subtype which has been implicated in abnormal wound healing and may help to explain the female preponderance of the disease. Work is ongoing to determine how this receptor is normally distributed, its normal function, and its possible role in this disease. You may read more about these findings in our publication:
Damrose EJ, Campbell RD, Darwish S, Erickson-DiRenzo E. Increased Expression of Estrogen Receptor Beta in Idiopathic Progressive Subglottic Stenosis. Laryngoscope. 2020 Sep;130(9):2186-2191.
Figure 1: Representative images of ER-α (A-D) and ER-β (E-H) in subglottic tissue of controls and specimens with idiopathic progressive subglottic stenosis (IPSS). Immunofluorescence demonstrated positive staining (green) for estrogen receptors. DAPI (blue) was used as a nuclear stain. A, no staining of ER-α in epithelium (Ep) and lamina propria (LP) of control specimen; B, strong staining of ER-α in Ep and LP in IPSS specimen; C, mild staining of ER-α in glands and ducts (G&D) of control; D, mild staining of ER-α in G&D of IPSS specimen; E, mild staining of ER-β in epithelium (Ep) and lamina propria (LP) of control; F, strong staining of ER-β in Ep and mild staining in LP of IPSS specimen; G, mild staining of ER-β in G&D of control; H, strong staining of ER-β in G&D of IPSS specimen.
Figure 2: Subglottic tissue from patient with idiopathic subglottic stenosis, stained with hematoxylin and eosin. Arrowhead = epithelium; arrow = lamina propria.
December 17, 2021
OHNS 2021 Education Updates
Our immensely talented trainee population includes 27 OHNS residents and 12 fellows/instructors, of which 3 are ACGME accredited fellows (one in pediatrics, two in neurotology), and the other 9 are instructors (two each in head and neck surgery, rhinology and sleep surgery, one in facial plastics and reconstructive surgery, one in laryngology, and one in pediatrics). We also have several graduate students, post-doctoral research fellows/instructors, and visiting scholars. Dozens of Stanford and visiting medical students are on rotation throughout the year.
The department has two residency tracks: a five-year “clinical track” (CT) and a seven-year “clinician scientist training program” (CSTP), which integrates two years of dedicated research following the third year of clinical training. The CSTP is a National Institute of Child Health and Human Development (NICHD) funded training program. The NIDCD supports and conducts research in the areas of hearing, balance, taste, smell, voice, speech, and language. their grant covers studies addressing the prevention, screening, diagnosing, and treatment of disorders of human communication.
More than 75% of our graduates have completed fellowship training. Recent residency graduates have taken positions attending Cornell University, Stanford, University of Chicago, University of Michigan, UCLA, and UCSF as well as in private practice settings such as Kaiser Permanente and Stanford’s University Health Alliance.
At the heart of the department’s education programs, the residency program provides a rigorous foundation of clinical training with a broad range of experiences in head and neck surgery, otology, rhinology, laryngology, facial plastic surgery, sleep surgery, audiology, allergy and pediatric otolaryngology. Furthermore, residents are exposed to diverse patient populations in various clinical settings. Besides Stanford Health Care (SHC Palo Alto), the primary site that residents spend approximately 35 months in, residents rotate between the Veterans Affairs Palo Alto Health Care System (VA), Santa Clara Valley Medical Center (SCVMC), and Lucile Packard Children’s Hospital Stanford (LPCH). They also spend time in SHC sites in East Palo Alto (Stanford Ear Institute) and Redwood City (sleep surgery).
Residents are required to meet all ACGME and American Board of Otolaryngology standards and expected to master the cognitive, clinical, procedural and professional skills required to function as attending otolaryngologists. They are assessed according to the ACGME Milestones and core competencies rubrics.
The program’s educational curriculum is designed to help each resident achieve their program goals while ensuring professional and personal growth in all possible directions whether basic or translational science, patient-oriented research, bio-technological innovation, or clinical practice and medical education.
December 17, 2021
OHNS 2021 Basic Science Research Updates
2021 is a year of new beginnings. Our research teams have transitioned into a new research space, the Biomedical Innovations building, and we have a new Chair, Konstantina Stankovic, onboarding and joining the ranks of outstanding clinician scientists within our group. As a team, we remain cognizant and grateful of our good fortune in being able to continue our research and teaching endeavors throughout the continued challenges created by the pandemic, social and political unrest, and wildfires and droughts. These challenges have strengthened us as a community, helped us focus on our priorities and furthered our resolve to be the best department and research group in the world. We continue to adapt, grow and support each other and our broad community to ensure that we all succeed together.
Research in OHNS crosses many boundaries from basic science to clinical studies, from cancer research to cell biology to big data RNAseq to single molecule tracking, and from hearing to smell to larynx to new surgical technologies. This breadth continues to grow with multiple ongoing searches in progress. To summarize everything happening would take a book, not a newsletter.
The following are highlights from this year. Stefan Heller’s team had published seven papers culminated from multi-year projects centered around identifying the biochemical pathways controlling hair cell regeneration in birds with a goal of mapping this pathway then stimulating it in mammalian systems. To this end, their parallel work in growing inner ear organoids had also made important breakthroughs. Dr. Cheng had published 13 papers with major contributions using single cell transcriptomics to define the heterogeneity of cell types in the mouse utricle. Drs. Grillet and Ó Maoiléidigh have started a robust collaboration to characterize hair cell and hair bundle morphology as a first step toward developing computational models on hair bundle mechanics. This work also resulted in a major publication. Dr. Nicolson had identified a novel genetic mutation that alters central processing of auditory information and shifted to this new direction to develop the tools needed for investigating central auditory defects. Dr. Ricci had four major publications with one focused on age-related hearing loss and another on aminoglycoside ototoxicity. And finally, we are proud to say that one of our lab mates who has worked in our core facility for the past 2.5 years, Murray Bartho, has been accepted into medical school and so will be leaving us to pursue these higher goals. As providing opportunities for training experiences is a priority of our group, we are excited for his progress and look forward to his future contributions.
There have been numerous other contributions from the scientists within our department and we will be highlighting them throughout the next year via our website and social media platforms, do check them out!
December 17, 2021
The Pediatric Otolaryngology division continues its mission to train future pediatric otolaryngologists and has expanded to 2 fellows this July. They welcome Brooke Su-Velez, MD, MPH, who completed her residency training at UCLA, and Taseer Din, MBChB, who completed his residency training at University of Cape Town, South Africa.
We would also like to congratulate Mai Thy Truong for her appointment as the Clinic Chief, and Kara Meister as the Associate Clinic Chief, in the division of Pediatric Otolaryngology at Stanford Children's Health. They will be part of the executive team that helps lead our growing clinical operations.
December 17, 2021
Treating advanced skin cancers with immunotherapy
Dr. Vasu Divi is transforming the way advanced skin cancers are treated — beginning not with surgery, but with immunotherapy.
In 2018 and 2020, the US FDA approved the use of immune checkpoint inhibitors (often called immunotherapy or an immuno-oncology; or IO) for the treatment of advanced skin cancer (cutaneous squamous cell carcinoma CutSCC). The central mechanism of IO is that immunotherapy “turns on” a patient’s immune system to identify then eliminate cancer cells. Many cancers (such as CutSCC) evade detection by tricking the human body to ignore cancerous growth, expressing a receptor or “tag” that turns off the body’s own natural defenses. These new IO treatments are shown a dramatic response for patients with CutSCC, eliminating all visible cancer in 10-20% of patients, with at least some meaningful response in almost half of all patients. The question is what to do after IO.
At Stanford, we believe that every patient benefits from a multi-disciplinary approach involving surgery, medical oncology, and radiation oncology. Dr. Divi’s study opens up new options for patients with advanced CutSCC, optimizing how the multidisciplinary team treats each individual patient precisely and with less toxicity and disfigurement.
December 17, 2021
Dr. Zara M. Patel, Associate Professor, is an endoscopic sinus and skull base surgeon who has also been researching olfactory dysfunction for the last decade. The current therapies being utilized to treat COVID19 related smell loss are largely based on research that she and others have performed on patients with olfactory loss prior to the pandemic (https://pubmed.ncbi.nlm.nih.gov/29901865/ ; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5527365/; https://pubmed.ncbi.nlm.nih.gov/31950156/).
Although these options can be helpful, there are still many patients who remain without their sense of smell despite treatment. Dr. Patel has thus continued her research in this area, recently culminating in Stanford University who filed a full US and International patent on her behalf. Although this patent initially centered around the invention of an endoscopic electrical stimulation device to speed regeneration of the olfactory nerve, due to her experience with endoscopic sinus and skull base surgery, it was broadened to include endoscopic electrical stimulation of all cranial nerves and ganglia as well as other tissues responsive to electrical stimulation that can be accessed endoscopically through the nasal cavity. The potential for improving patients’ lives spans disorders such as chronic sinusitis, facial pain, facial paralysis, visual problems, endocrine problems, and more.
Dr. Patel also creates biweekly reports on global, national, state and regional data regarding the COVID19 pandemic to inform the leadership of Stanford School of Medicine and the Stanford community at large. She has assumed the role from Dr. Robert Jackler, who founded the report service early in the COVID19 pandemic in order to bring essential information to the community at a critical time. Dr. Patel releases these reports to the public as well to help as many people as possible make informed decisions to keep themselves and their families safe and healthy. See: https://youtu.be/sj3dteQnbQo
Dr. Nayak, along with his laboratory group in the Department of Otolaryngology, have secured 5 years of competitive research funding from the National Institutes of Health (NIH) on March 1, 2021. This $2.4M federal grant, termed an R01 award, was bestowed by the National Heart, Lung and Blood Institute (NHLBI) in Bethesda, MD until at least January 2026 to support Dr. Nayak’s groundbreaking work in optimizing the transplantation and long-term engraftment of human airway stem cells in live animal models.
This R01 grant was supported by contributions from several co-Investigators on this award, all within Stanford University. They include Drs. Matthew Porteus (Department of Pediatrics and Biochemistry), Tushar Desai (Department of Pulmonary Critical Care Medicine), Y. Peter Yang (Department of Orthopedics), and Jeffrey Wine (Department of Psychology, CF Biology).
Dr. Hwang, Professor and Chief of the Division of Rhinology & Endoscopic Skull Base Surgery, was recently awarded a Presidential Citation from the American Rhinologic Society in recognition of his distinguished service to the society. Dr. Hwang has served in a variety of leadership roles over the years, including Board of Directors, Secretary, and President. He continues to serve as founder and co-director of the society's Mentorship Program.
December 17, 2021
Stanford founding a world center for comprehensive sleep medicine and surgery.
The pioneering work done here by William Dement, Christian Guilleminault, Richard Goode, Robert Riley and Nelson Powell established the original Stanford Sleep Surgery protocol. Inheriting this remarkable legacy are Robson Capasso, MD, FAASM, Chief of the Sleep Surgery Division and dual trained and board-certified in both Sleep Medicine and Head and Neck Surgery, and Stanley Liu, MD, DDS, dual trained and board certified in Maxillofacial Surgery and Sleep Surgery.
Drs. Capasso and Liu collaborate closely to meet the needs of any OSA patient and continue to refine and expand the original Stanford Sleep Surgery protocol to offer precise, individualized care.
However, this poses several challenges. Defining the best OSA surgical treatment path hinges on the accurate definition of “successful result”; Some of the commonly used sleep study metrics have little to no correlation with clinically meaningful outcomes and offer limited perspectives on the ideal surgical procedure for each individual. In addition, decisions around procedure selection and perioperative routines are based on less-than-ideal evidence to support or refute its usefulness.
To target this issue, Dr. Capasso gathered multidisciplinary talent and assembled a team with computer science and statistics expertise aiming to collect, refine and analyze large volumes of data to generate Real World Evidence that can assist in defining clinically relevant deliverables and peri-operative efficient routines. In the future, AI in the form of algorithmic agents may permeate such an environment and work in tandem with the human members of our care team.
Craniofacial procedures can offer complexity on its planning and execution. Dr Liu is developing scholar work on novel surgical techniques aiming to improve the upper airway following facial skeletal procedures while preserving facial balance and adequate occlusion. A novel aspect, however, is the improvement of nasal breathing following targeted distraction osteogenesis maxillary expansion (DOME), a procedure with limited morbidity and usually fast recovery.