Bio

Clinical Focus


  • Endoscopic Skull Base Surgery
  • Endoscopic Sinus Surgery
  • Otolaryngology - Head & Neck Surgery (Ear, Nose and Throat)
  • Otolaryngology

Academic Appointments


Administrative Appointments


  • Chief, Division of Rhinology & Endoscopic Skull Base Surgery, Stanford School of Medicine (2005 - Present)
  • Co-Director, Fellowship in Rhinology & Endoscopic Skull Base Surgery, Stanford University (2005 - Present)

Boards, Advisory Committees, Professional Organizations


  • 1st Vice President, American Rhinologic Society (2013 - Present)
  • Associate Editor, International Forum of Allergy & Rhinology (2011 - Present)

Professional Education


  • Residency:Univ of California San Francisco (1996) CA
  • Internship:Univ of California San Francisco (1992) CA
  • Medical Education:Univ of California San Francisco (1991) CA
  • Board Certification: Otolaryngology, American Board of Otolaryngology (1997)
  • Fellowship:University of Pennsylvania (1997) PA
  • Fellowship, Univ. of Pennsylvania, Rhinology & Sinus Surgery (1997)
  • Residency, UC San Francisco, Otolaryngology (1996)
  • MD, UC San Francisco (1991)
  • BS, Stanford University, Biology (1987)

Research & Scholarship

Current Research and Scholarly Interests


- Characterization of ion transport activity in sinonasal epithelium
- Optimization of mucosal wound healing in a rabbit model of sinus surgery
- Clinical outcomes in patients with chronic rhinosinusitis undergoing endoscopic sinus surgery
- Effect of intraoperative local anesthetic use on post operative pain in patients undergoing endoscopic sinus surgery

Teaching

2013-14 Courses


Publications

Journal Articles


  • Endoscopic Hydroxyapatite Augmentation for Patulous Eustachian Tube LARYNGOSCOPE Vaezeafshar, R., Turner, J. H., Li, G., Hwang, P. H. 2014; 124 (1): 62-66

    Abstract

    To evaluate the safety and efficacy of endoscopic calcium hydroxyapatite injection in patients with patulous Eustachian tube.Retrospective case series.Fourteen patients diagnosed with patulous Eustachian tube (PET) underwent endoscopic hydroxyapatite injection under general anesthesia. All patients had at least two of three major PET symptoms including voice autophony, breathing autophony, or aural fullness/pressure. Patients were evaluated postoperatively with nasal endoscopy and a symptom questionnaire.Endoscopic Eustachian tube injection was performed in a total of 23 sides in 14 patients with an average volume of 2.1 cc injected per side. Mean follow-up was 17.5 months. The most common symptoms reported preoperatively were voice autophony (96%), breathing autophony (91%), and ear fullness (83%). A complete or significant response to treatment was noted in 13/22 sides with voice autophony (59%), 12/21 sides with breathing autophony (57%), and 12/19 sides with ear fullness (63%). All complete or significant symptom improvements remained durable through the entirety of the follow-up period. Four sides that had temporary or no improvement with treatment underwent repeat injection but did not achieve additional improvement. No intraoperative or postoperative complications were observed.Endoscopic hydroxyapatite injection of the Eustachian tube is a minimally invasive procedure that provided significant or complete relief of autophony and ear fullness in 57% to 63% of sides treated. The procedure is well tolerated and can be performed safely under endoscopic visualization. Hydroxyapatite injection may be a satisfactory alternative to more invasive treatments for PET.4. Laryngoscope, 2013.

    View details for DOI 10.1002/lary.24250

    View details for Web of Science ID 000328738800019

    View details for PubMedID 23775903

  • Pretreatment of sinus aspirates with dithiothreitol improves yield of fungal cultures in patients with chronic sinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Chisholm, K. M., Getsinger, D., Vaughan, W., Hwang, P. H., Banaei, N. 2013; 3 (12): 992-996

    Abstract

    Mold pathogens are a leading cause of chronic rhinosinusitis. Successful isolation of mold on culture is helpful in establishing a diagnosis and guiding therapy. Though mucolytic agents are commonly used in European countries, they are not part of everyday use in North America. In this case-control prospective study, we investigated the yield of fungal culture before and after treatment of sinus aspirates with the mucolytic agent dithiothreitol in a United States hospital.Over a 5-month period during 2011-2012, 359 sinus aspirates from 294 patients with symptoms suspicious for chronic sinusitis or allergic fungal sinusitis were collected. Aspirates were cultured on fungal medium before and after treatment with dithiothreitol.Of the 359 pairs of cultures, 62 (17.3%) demonstrated mold growth on at least 1 of the plates, 9 (14.5%) of which grew more than 1 species of mold. A total of 75 molds were identified, 41 (54.7%) of which were successfully cultured only when the mucus was pretreated with dithiothreitol (p < 0.0001). Quantitatively, more colonies grew from dithiothreitol-treated mucus than from direct-inoculation (p < 0.0001).This study confirms improved recovery of mold from sinus cultures after pretreatment of samples with dithiothreitol. Further studies are needed to correlate these findings with clinical outcome.

    View details for DOI 10.1002/alr.21230

    View details for Web of Science ID 000328300500008

    View details for PubMedID 24124079

  • Systemic prednisone administration selectively alters granulocyte subsets in nasal polyps from aspirin-exacerbated respiratory disease and chronic rhinosinusitis patients. International forum of allergy & rhinology Edward, J. A., Sanyal, M., Ramakrishnan, V. R., Le, W., Nguyen, A. L., Kingdom, T. T., Hwang, P. H., Nayak, J. V. 2013; 3 (11): 866-876

    Abstract

    Nasal polyps (NPs) are hallmark inflammatory lesions of sinusitis. Despite the spectrum of NP conditions, cellular differences between NPs from patients with chronic rhinosinusitis with NPs (CRSwNP) and aspirin-exacerbated respiratory disease (AERD) are poorly understood. NPs are associated with abundant eosinophils; the contributions of neutrophil and basophil granulocytes are less defined. We therefore sought to assess granulocyte subpopulations, and differential effects following prednisone pretreatment, within NPs of CRSwNP and AERD patients.NPs, adjacent ethmoid sinus tissue, and peripheral blood mononuclear cells (PBMCs) were obtained from patients undergoing endoscopic sinus surgery. Samples from 5 cohorts: CRSwNP ± prednisone (n = 6 each), AERD ± prednisone (n = 6 each), and controls (n = 9), were analyzed by high-dimensional flow cytometry to gate granulocyte populations. Specimens were also assessed using immunohistochemistry (IHC) staining.Systemic prednisone administration was associated with a lower frequency of eosinophils (p < 0.0001, n = 6) in NPs in both CRSwNP and AERD patients, whereas a decrease in neutrophils (p = 0.0070, n = 6) in NPs was only observed in CRSwNP patients after prednisone treatment. In contrast, steroids do not alter basophil proportions (p = 0.48, n = 6) within NPs from either group. No significant shift in granulocyte subsets after steroid treatment was identified in the adjacent ethmoid mucosa or PBMCs from the same patients. Immunohistochemistry (IHC) staining supported these findings.Granulocyte subpopulations are focally affected within NPs by systemic steroid exposure, without notable granulocyte alterations in the surrounding regional tissues. These data provide direct insights into the cellular effects of routine prednisone exposure in CRS patients, and highlight a unique microenvironment present within NP lesions.

    View details for DOI 10.1002/alr.21221

    View details for PubMedID 24106221

  • Characterization of human upper airway epithelial progenitors. International forum of allergy & rhinology Bravo, D. T., Soudry, E., Edward, J. A., Le, W., Nguyen, A. L., Hwang, P. H., Sanyal, M., Nayak, J. V. 2013; 3 (10): 841-847

    Abstract

    New epithelial cells are generated through the proliferation and differentiation of resident progenitor cells in the nasal cavity. In several upper airway diseases, such as cystic fibrosis and chronic rhinosinusitis, self-renewing progenitor cells may be functionally defective, or compromised in their ability, to regenerate cells that maintain normal mucociliary clearance. Herein, we describe our early work to define and characterize a rare population of human nasal epithelial putative progenitors.Single-cell suspensions of human ethmoid sinus tissues were prepared following endoscopic sinus surgery. Cell surface antibodies were analyzed as candidate markers for detecting progenitor cells. A panel of antibodies, including epithelial cell adhesion molecule (EpCAM, epithelial cells), CD45 (hematopoietic cells), nerve growth factor receptor (NGFR/CD271), intercellular adhesion molecule-1 (ICAM1/CD54), and integrin-α6 (ITGA6/CD49f) were used to resolve epithelial progenitor candidates by high-dimensional flow cytometry and the gating technique of fluorescence minus one (FMO) controls.A rare population of approximately 0.06% of total ethmoid cells was discriminated as EpCAM(-) CD45(-) NGFR(+) ICAM1(+) by surface markers. Use of ITGA6 was excluded based on FMO control analysis. This lineage-negative population was purified to 99% homogeneity by cell sorting and analyzed by immunofluorescence microscopy. Sorted cells were subsequently confirmed to uniformly express the transcription factor p63. Upon in vitro culture, lineage-negative clonal cells were confirmed to spontaneously differentiate into epithelial lineage-positive cells.Using the NGFR and ICAM1 cellular coordinates, we have identified a promising population of native human nasal epithelial progenitor cells that require more formal investigation for their role in upper airway regeneration.

    View details for DOI 10.1002/alr.21205

    View details for PubMedID 23901007

  • Patient-Centered Decision Making in the Treatment of Chronic Rhinosinusitis LARYNGOSCOPE Soler, Z. M., Rudmik, L., Hwang, P. H., Mace, J. C., Schlosser, R. J., Smith, T. L. 2013; 123 (10): 2341-2346

    Abstract

    To explore possible factors that might impact a patient's choice to pursue endoscopic sinus surgery (ESS) or continue with medical management for treatment of refractory chronic rhinosinusitis (CRS).Cross-sectional evaluation of a multicenter prospective cohort.Two hundred forty-two subjects with CRS were prospectively enrolled within four academic tertiary care centers across North America with ongoing symptoms despite prior medical treatment. Subjects either self-selected continued medical management (n = 62) or ESS (n = 180) for treatment of sinonasal symptoms. Differences in demographics, comorbid conditions, and clinical measures of disease severity between subject groups were compared. Validated metrics of social support, personality, risk aversion, and physician-patient relationships were compared using bivariate analyses, predicted probabilities, and receiver operating characteristic curves at the 0.05 alpha level.No significant differences were found between treatment groups for any demographic characteristic, clinical cofactor, or measure of social support, personality, or the physician-patient relationship. Subjects electing to pursue sinus surgery did report significantly worse average quality-of-life (QOL) scores on the 22-item Sinonasal Outcome Test (SNOT-22; P < .001) compared to those electing continued medical therapy (54.6 ± 18.9 vs. 39.4 ± 17.7), regardless of surgical history or polyp status. SNOT-22 score significantly predicted treatment selection (odds ratio, 1.046; 95% confidence interval, 1.028-1.065; P < .001) and was found to accurately discriminate between subjects choosing endoscopic sinus surgery and those electing medical management 72% of the time.Worse patient-reported disease severity, as measured by the SNOT-22, was significantly associated with the treatment choice for CRS. Strong consideration should be given for incorporating CRS-specific QOL measures into routine clinical practice.2b. Laryngoscope, 2013.

    View details for DOI 10.1002/lary.24027

    View details for Web of Science ID 000325091100005

    View details for PubMedID 23856802

  • Distribution of topical agents to the paranasal sinuses: an evidence-based review with recommendations INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Thomas, W. W., Harvey, R. J., Rudmik, L., Hwang, P. H., Schlosser, R. J. 2013; 3 (9): 691-703

    Abstract

    BACKGROUND: The objective of this work was to review the literature concerning the distribution of topical therapeutics to the sinuses versus nasal cavity regarding: surgical state, delivery device, head position, and nasal anatomy and to provide evidence-based recommendations. METHODS: A systematic review was conducted using Medline, EMBASE, and Cochrane databases to perform a Medical Subject Heading search of the literature from 1946 until the last week of May 2012. Articles were independently reviewed and graded for level of evidence. All authors came to consensus on recommendations through an iterative process. RESULTS: Recommendations were made for: improved sinus delivery with high-volume devices and after standard sinus surgery. Recommendations were made against low-volume delivery devices, such as drops, sprays, or simple nebulizers as they do not reliably reach the sinuses. If large-volume devices are not tolerated, low-volume devices are recommended using the lying head back or lateral head low positions to improve nasal cavity distribution to the middle meatus or olfactory cleft. CONCLUSION: Surgery, volume of device, head position, and nasal anatomy were shown to impact distribution to the sinuses. Recommendations are made based upon this evidence as to how to best maximize therapeutic distribution to the sinuses.

    View details for DOI 10.1002/alr.21172

    View details for Web of Science ID 000325111500002

    View details for PubMedID 23729216

  • Survival outcomes in acute invasive fungal sinusitis: A systematic review and quantitative synthesis of published evidence. Laryngoscope Turner, J. H., Soudry, E., Nayak, J. V., Hwang, P. H. 2013; 123 (5): 1112-1118

    Abstract

    Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. The current study systematically reviews and quantitatively synthesizes the published literature to characterize prognostic factors associated with survival.Systematic review.Fifty-two studies comprising a total of 807 patients met inclusion criteria and were used for analysis of treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors.All studies were classified as level 4 evidence, as per definitions provided by the Oxford Center for Evidence-Based Medicine. The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall survival rate was 49.7%. On univariate analysis, poor prognosis was associated with renal/liver failure, altered mental status, and intracranial extension. Patients who were diabetic, had surgery, or received liposomal amphotericin B had an improved chance of survival. On multivariate analysis, advanced age and intracranial involvement were identified as independent negative prognostic factors. Positive prognostic factors again included diabetes and surgical resection.The overall mortality of patients with AIFS remains high, with only half of the patients surviving. Diabetic patients appear to have a better overall survival than patients with other comorbidities. Patients who have intracranial involvement, or who do not receive surgery as part of their therapy, have a poor prognosis.N/A.

    View details for DOI 10.1002/lary.23912

    View details for PubMedID 23300010

  • Expression of dual oxidases and secreted cytokines in chronic rhinosinusitis. International forum of allergy & rhinology Cho, D., Nayak, J. V., Bravo, D. T., Le, W., Nguyen, A., Edward, J. A., Hwang, P. H., Illek, B., Fischer, H. 2013; 3 (5): 376-383

    Abstract

    The airway epithelium generates reactive oxygen species (ROS) as a first line of defense. Dual oxidases (DUOX1 and DUOX2) are the H2 O2 -producing isoforms of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase family in the airway epithelium. The purpose of this study was to explore the molecular expression, function, and regulation of DUOXs in chronic rhinosinusitis (CRS).Human nasal tissue samples and nasal secretions were collected from 3 groups of patients undergoing sinus surgery (normal, n = 7; CRS with polyposis [CRSwP], n = 6; CRS without polyposis [CRSsP], n = 6). Nasal secretions were studied for cytokine and H2 O2 content. Tissue samples were used to determine DUOX mRNA and protein expression.DUOX1 mRNA level (80.7 ± 60.5) was significantly increased in CRSwP compared to normal (2.7 ± 1.2) and CRSsP (2.3 ± 0.5, p = 0.042). DUOX2 mRNA levels were increased in both CRSwP (18.6 ± 9.9) and CRSsP (4.0 ± 1.3) compared to normal (1.1 ± 0.3; p = 0.008). DUOX protein was found in the apical portion of the nasal epithelium and protein expression was increased in CRSwP and CRSsP. H2 O2 production was significantly higher in CRSwP (160.9 ± 59.4 nM) and CRSsP (81.7 ± 5.6 nM) compared to normal (53.5 ± 11.5 nM, p = 0.032). H2 O2 content of nasal secretions correlated tightly with DUOX expression (p < 0.001). Cytokines (eotaxin, monokine-induced by interferon ? [MIG], tumor necrosis factor [TNF]-?, interleukin [IL]-8) showed significantly higher levels in nasal secretions from CRSwP compared to normal (p < 0.05). Levels of eotaxin, MIG, and TNF-? correlated closely with DUOX expression.DUOX1 and DUOX2 were identified as factors upregulated in CRS. Close correlations between DUOX expression and H2 O2 release, and correlation between key inflammatory cytokines and DUOX expression, indicate DUOX in the inflammatory response in CRS.

    View details for DOI 10.1002/alr.21133

    View details for PubMedID 23281318

  • Endoscopic endonasal anatomy of the nasopharynx in a cadaver model INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Becker, A. M., Hwang, P. H. 2013; 3 (4): 319-324

    Abstract

    Nasopharyngectomy is an accepted treatment for recurrent nasopharyngeal carcinoma following radiation with or without chemotherapy. Traditionally, the nasopharynx has been approached through relatively invasive "open" techniques including transpalatal, maxillary swing, and trans-mandibular-pterygoid approaches. Contemporary management has included the use of endoscopic techniques to exenterate tumors in this location. The purpose of the present study is to describe the endoscopic anatomy of this region through cadaveric dissection and to characterize the technical limitations of the approach.Five fresh cadaveric heads were dissected to study the endoscopic anatomy of the nasopharynx and associated structures.Endoscopic dissection of the nasopharynx was completed in all 5 specimens. Nasopharyngeal anatomy including the buccopharyngeal fascia, pharyngobasilar fascia, superior constrictor, longus capitus, longus coli, fossa of Rosenmuller, basisphenoid, auditory torus, and internal carotid artery were characterized.Surgical access to the nasopharynx has posed significant challenges in the treatment of recurrent or persistent nasopharyngeal carcinoma. This study demonstrated that endoscopic dissection of this region is feasible and has the potential to completely exenterate these lesions.

    View details for DOI 10.1002/alr.21104

    View details for Web of Science ID 000317362900010

    View details for PubMedID 23109510

  • Basal lamella relaxing incision improves endoscopic middle meatal access INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Getz, A. E., Hwang, P. H. 2013; 3 (3): 231-235

    Abstract

    Lateralization of the middle turbinate is a commonly cited factor leading to failure of functional endoscopic sinus surgery (FESS). Inadequate medialization during FESS may require repeat intraoperative attempts, and may lead to destabilization and mucosal trauma. A novel technique is described that increases middle meatal area and provides more definitive medialization at the outset of FESS.Twenty-nine middle turbinate medializations were prospectively evaluated in 18 consecutive patients undergoing primary ESS. Three intraoperative images of the middle meatus were obtained in the native position, after Freer medialization, and after basal lamella relaxing incision (BLRI). Measurements of middle meatal area were then calculated in a blinded and randomized fashion.Distances measured from the middle turbinate to the lateral nasal wall for each position ranged from 0 to 8 mm (median = 3.00 mm) for the native position, 0.5 to 10 mm (median = 5.00 mm) for standard Freer medialization, and 3 to 21 mm (median = 10.00 mm) for BLRI. Friedman's analysis of variance (ANOVA) showed that there was significant difference between the 3 measurements, and the post hoc Wilcoxon signed ranks tests showed that BLRI distance (median = 10; 95% confidence interval [CI], 7-11.2) was significantly larger than both standard Freer (median = 5; 95% CI, 4-6.2) and native (median = 3; 95% CI, 2-3) and that standard Freer was significantly larger than native (all p values <0.001).BLRI is a safe, controlled technique that provides significantly greater medialization of the middle turbinate compared to standard medialization techniques. BLRI significantly enhances the operative space within the middle meatus.

    View details for DOI 10.1002/alr.21086

    View details for Web of Science ID 000316265000012

    View details for PubMedID 23038164

  • Trends in incidence and susceptibility among methicillin-resistant Staphylococcus aureus isolated from intranasal cultures associated with rhinosinusitis. American journal of rhinology & allergy Rujanavej, V., Soudry, E., Banaei, N., Baron, E. J., Hwang, P. H., Nayak, J. V. 2013; 27 (2): 134-137

    Abstract

    Reports regarding the incidence and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) in rhinosinusitis (RS) are limited. This study was designed to identify epidemiology and trends of MRSA incidence and antimicrobial resistance in the sinonasal cavities.This is a retrospective case series. All intranasal/sinus cultures obtained by otolaryngologists at Stanford over a 20-year period (1990-2010) were retrospectively reviewed by mining the microbiology database. Nested searches were then made for all S. aureus and MRSA cultures. Patterns of incidence and changes in antibiotic susceptibilities were tabulated and statistical analysis was performed.Our search retrieved 10,387 positive intranasal culture samples, with S. aureus found in 800 (7.7%), and MRSA comprising 110 (1.06%) of this subset. Between the years of 1990 and 1999, only 2/112 (1.7%) of S. aureus-positive nasal cultures were positive for MRSA, with a sharp rise in incidence to 86/606 (14.2%) from 2000 to 2005, and to 22/82, 26.8% from 2006 to 2010. On a percent basis, using logistic regression modeling, this represents a statistically significant increasing trend (p < 0.0001) for MRSA sinusitis. However, over the 20-year interval studied, the patterns of antibiotic resistance among MRSA remained unaltered, especially with regard to trimethoprim-sulfamethoxazole and vancomycin.S. aureus and MRSA isolates from intranasal cultures, which were essentially absent before the year 2000, became significantly more common earlier this decade. These data show the increased role of MRSA in sinusitis. MRSA antibiotic susceptibilities have remained, however, largely stable during this time period.

    View details for DOI 10.2500/ajra.2013.27.3858

    View details for PubMedID 23562203

  • Staph aureus has long been recognized as being more prevalent in cultures from patients with chronic rhinosinusitis(CRS) compared to those with acute rhinosinusitis. International forum of allergy & rhinology Hwang, P. H. 2013; 3 (2): 81-82

    View details for DOI 10.1002/alr.21155

    View details for PubMedID 23413117

  • Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Poetker, D. M., Jakubowski, L. A., Lal, D., Hwang, P. H., Wright, E. D., Smith, T. L. 2013; 3 (2): 104-120

    Abstract

    Oral steroids are commonly used in the management of chronic rhinosinusitis (CRS) with and without nasal polyps (CRSwNP and CRSsNP, respectively). Past reports have included evaluation of the evidence for the use of oral steroids in CRS subtypes. However, a review with evidence-based recommendations for all CRS subtypes has never been performed. The purpose of this article is to provide a comprehensive, evidence-based approach for the utilization of oral steroids in the management of CRS.A systematic review of the literature was performed following recommendations of the Clinical Practice Guideline Manual, Conference on Guideline Standardization, and Appraisal of Guidelines and Research Evaluation. Inclusion criteria were: adult population ? 18 years old; CRS; oral steroids as the treatment group; and clearly defined primary clinical end-point.This review identified and evaluated the literature on the use of oral steroids for CRSwNP, CRSsNP, allergic fungal sinusitis (AFS), and the use of oral steroids in the perioperative period in these patients. Recommendations based on evidence, benefit/harm assessment, and value judgments are made.Oral steroids are strongly recommended for short-term management of CRSwNP. Oral steroids are also recommended for management of AFS. Oral steroid use in CRSsNP is optional due to insufficient strong evidence. Oral steroids are also strongly recommended in the perioperative period for CRSwNP and AFS. There is no recommendation for oral steroids use in the perioperative period in patients with CRSsNP. The risks of oral steroids are rare, but significant adverse effects must be considered.

    View details for DOI 10.1002/alr.21072

    View details for Web of Science ID 000315141700006

    View details for PubMedID 22887970

  • The endoscopic-assisted trephination approach for repair of frontal sinus cerebrospinal fluid leaks LARYNGOSCOPE Crozier, D. L., Hwang, P. H., Goyal, P. 2013; 123 (2): 321-325

    View details for DOI 10.1002/lary.23499

    View details for Web of Science ID 000314985400006

    View details for PubMedID 22952018

  • Balloon Dilation of the Sinuses ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Hwang, P. H. 2012; 138 (11): 1077-1079

    View details for Web of Science ID 000312400100012

    View details for PubMedID 23165383

  • Interrater agreement of nasal endoscopy in patients with a prior history of endoscopic sinus surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY McCoul, E. D., Smith, T. L., Mace, J. C., Anand, V. K., Senior, B. A., Hwang, P. H., Stankiewicz, J. A., Tabaee, A. 2012; 2 (6): 453-459

    Abstract

    Nasal endoscopy is an important part of the clinical evaluation of patients with chronic rhinosinusitis. However, the objectivity and interrater agreement of the procedure related findings have not been well studied, especially in patients who have previously had sinus surgery.Patients with a history of endoscopic sinus surgery for chronic rhinosinusitis were prospectively enrolled from a tertiary rhinology practice. Fourteen endoscopic nasal examinations were recorded using digital video capture software. Each patient also underwent computed tomography (CT) and completed the Sinonasal Outcome Test (SNOT-22). Blinded review of inflammatory and anatomic findings for each video was independently performed by 5 academic rhinologists at separate institutions. Comparisons were performed using the unweighted Fleiss' kappa statistic (K(f) ) and the prevalence- and bias-adjusted kappa (PABAK).There were no significant correlations between age, Lund-Mackay score, or SNOT-22 score. Interrater agreement was variable across the characteristics studied. Mean PABAK was excellent for the assessment of polyps (K(f) = 0.886); moderate for the assessments of middle turbinate (MT) integrity (K(f) = 0.543), MT position (K(f) = 0.443), maxillary sinus patency (K(f) = 0.593), and ethmoid sinus patency (K(f) = 0.429); fair for discharge (K(f) = 0.314), synechiae (K(f) = 0.257), and middle meatus patency (K(f) = 0.229); and poor for MT mucosal changes (K(f) = 0.148) and uncinate process (K(f) = 0.126).This study was notable for variability in the interrater agreement among the inflammatory and anatomic attributes that were examined. Further standardization of nasal endoscopy with regard to interpretation may improve the reliability of this procedure in clinical practice.

    View details for DOI 10.1002/alr.21058

    View details for Web of Science ID 000312142200004

    View details for PubMedID 22696506

  • Mucocele formation under pedicled nasoseptal flap AMERICAN JOURNAL OF OTOLARYNGOLOGY Vaezeafshar, R., Hwang, P. H., Harsh, G., Turner, J. H. 2012; 33 (5): 634-636

    Abstract

    The pedicled nasoseptal flap has become an indispensible tool for the reconstruction of skull base defects. This flap is easily harvested, provides a large surface area of vascularized tissue, and has few reported complications. We describe the case of a 60-year-old man who underwent endoscopic, endonasal transsphenoidal surgery with septal flap reconstruction who developed a sphenoid sinus mucocele postoperatively. We also have reviewed the literature for similar findings and discuss this complication in the setting of pituitary surgery and endoscopic skull base repair. Although likely a rare occurrence, mucocele formation after septal flap reconstruction should be recognized and monitored with postoperative nasal endoscopy and radiologic imaging. Reoperation or mucocele drainage may be necessary if symptomatic or in cases of rapid enlargement.

    View details for DOI 10.1016/j.amjoto.2012.05.003

    View details for Web of Science ID 000308833800028

    View details for PubMedID 22771247

  • Low-frequency pulsed ultrasound in the nasal cavity and paranasal sinuses: a feasibility and distribution study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Patel, Z. M., Hwang, P. H., Chernomorsky, A., Bravo, D. T., Nguyen, B. L., Nesterova, K., Nayak, J. V. 2012; 2 (4): 303-308

    Abstract

    Bacterial biofilms have been implicated in refractory rhinosinusitis. Biofilms have been shown to respond to treatment with low-frequency ultrasound (LFU) therapy in vitro, and exposure to LFU has shown efficacy in wound repair and topical drug delivery in other fields. This preliminary study was designed to evaluate the safety and feasibility of LFU for use in the nasal cavity and paranasal sinuses.This was an experimental observational study. Six cadaver heads were used to deliver a mixture of Renografin and methylene blue solvent to the paranasal sinuses via LFU both before and after resident endoscopic sinus dissection. Sinus computed tomography (CT) scans of the cadaver heads were performed before and after mixture delivery, and blinded assessments were made for distribution to individual sinuses. Mucosa was harvested from 2 subsites to evaluate LFU-treated cadaver tissue.Predissection, LFU delivered solution to 12 of 12 inferior and middle turbinates, 6 of 12 of the superior turbinates and ethmoid sinuses, and 1 of 12 maxillary sinuses as shown by contrast radiography. Postdissection, all heads showed delivery to the maxillary and sphenoid sinuses, with 8 of 12 sinus cavities showing delivery to the ethmoid region, and 4 of 11 to the frontal recess. Using hematoxylin and eosin (H&E) staining of tissue frozen sections, harvested tissue demonstrated no architectural damage to the mucosal layer from LFU exposure.LFU appears to be capable of reliably delivering topical solution to the turbinates and ethmoid region preoperatively and to all sinuses, except the frontal, postoperatively. The nasal epithelium does not appear to be disrupted histologically from LFU at this time and distance. This data provides a foundation for a prospective human protocol studying the efficacy of this modality in the treatment of patients with chronic rhinosinusitis and biofilm formation.

    View details for DOI 10.1002/alr.21039

    View details for Web of Science ID 000308927400007

    View details for PubMedID 22528624

  • Epigenetic modifications and improved regulatory T-cell function in subjects undergoing dual sublingual immunotherapy JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY Swamy, R. S., Reshamwala, N., Hunter, T., Vissamsetti, S., Santos, C. B., Baroody, F. M., Hwang, P. H., Hoyte, E. G., Garcia, M. A., Nadeau, K. C. 2012; 130 (1): 215-?

    Abstract

    Allergen-specific immunotherapy is the only mode of therapy that has been demonstrated to offer a cure in patients with IgE-mediated respiratory allergies.We sought to demonstrate the safety and efficacy of timothy grass (TG) and dust mite (DM) dual sublingual immunotherapy (SLIT) and to begin to investigate the immune mechanisms involved in successful immunotherapy with multiple allergens.The safety and efficacy of dual SLIT with TG and DM in children and adults with demonstrated allergies to TG and DM were investigated in a single-center, randomized, double-blind, controlled phase I study. Thirty subjects received either TG and DM dual SLIT (n= 20) or placebo (n = 10). Immune parameters were evaluated for differentiation of desensitized subjects from control subjects.Subjects treated with dual SLIT had decreased rhinoconjunctivitis scores (P < .001) and medication use scores (P < .001) and reduced responses to TG and DM allergen based on results of skin prick tests or nasal disk challenges (P < .01 and P < .001, respectively) compared with placebo-treated control subjects. An increase in TG- and DM-specific IgG(4) levels, reduced allergen-specific IgE levels, and subsequent basophil activation were observed in the active treatment group. Dual SLIT promoted allergen-specific suppressive CD4(+)CD25(high)CD127(low)CD45RO(+) forkhead box protein 3 (Foxp3)(+) memory regulatory T cells with reduced DNA methylation of CpG sites within the Foxp3 locus.The results of this pilot study suggest that dual SLIT could be an effective means to treat subjects with sensitivities to a variety of allergens and that long-term tolerance might be induced by epigenetic modifications of Foxp3 in memory regulatory T cells.

    View details for DOI 10.1016/j.jaci.2012.04.021

    View details for Web of Science ID 000306644800030

    View details for PubMedID 22677046

  • Targeted endoscopic salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Ho, A. S., Kaplan, M. J., Fee, W. E., Yao, M., Sunwoo, J. B., Hwang, P. H. 2012; 2 (2): 166-173

    Abstract

    Despite modern radiotherapy and open surgical techniques, treatment of recurrent nasopharyngeal carcinoma (NPC) remains challenging, with substantial morbidity involved. Targeted endoscopic nasopharyngectomy was evaluated as a viable oncologic alternative to open nasopharyngectomy or radiation for recurrent NPC.Thirteen patients who underwent endoscopic nasopharyngectomy for recurrent NPC between August 2005 and August 2010 were retrospectively reviewed. Average age at surgery was 55.7 years, with mean follow-up period 24.2 months. Two-year disease-free survival, 2-year overall survival, margin status, and complication rate were measured.Including resections for subsequent recurrences, 19 endoscopic procedures were performed with curative intent. Mean operating room (OR) time was 278 minutes, mean estimated blood loss was 197 mL, and mean length of hospitalization was 1.0 days. Negative margins were obtained in 78.9% of procedures: positive margins involved the parapharyngeal space, oropharynx, fossa of Rosenmuller, and infratemporal fossa. Stereotactic radiation was given postoperatively for localized positive margins. Four patients required repeat endoscopic nasopharyngectomy for re-recurrence, despite having their margins cleared or controlled with adjuvant treatment. Two-year local disease-free and overall survival rates were 69.2% and 100.0%, respectively. The overall minor complication rate was 52.6%, with no major complications.Targeted endoscopic nasopharyngectomy is beneficial in locally recurrent NPC, with favorable morbidity and complication rates. Endoscopic surveillance and serial imaging together facilitate the early identification of re-recurrences, which often may be treated with additional directed resection. Postoperative stereotactic radiation may serve as an appropriate adjunct modality for disease control at positive margins.

    View details for DOI 10.1002/alr.20111

    View details for Web of Science ID 000308926000015

    View details for PubMedID 22170783

  • Nationwide incidence of major complications in endoscopic sinus surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Ramakrishnan, V. R., Kingdom, T. T., Nayak, J. V., Hwang, P. H., Orlandi, R. R. 2012; 2 (1): 34-39

    Abstract

    Endoscopic sinus surgery (ESS) is one of the most commonly performed procedures in otolaryngology. Major complications are estimated to occur in 1-3% of cases, based on early studies with relatively small patient cohorts in academic institutions. The aim of this study was to update data regarding major complication rates associated with ESS by analyzing a large patient database.Retrospective review of a nationwide database of patients who underwent ESS between 2003 and 2007. Major postoperative complications-cerebrospinal fluid (CSF) leak, orbital injury, and hemorrhage requiring blood transfusion-were identified by searching the database for related International Classification of Diseases, 9th edition (ICD-9) and Current Procedural Terminology (CPT) codes. Complication rates were examined and time to occurrence analyzed. Two-tailed test of proportions, global chi-square test, and logistical regression analysis were used for statistical comparison.A total of 62,823 patients who met rigorous inclusion criteria were included. The overall major complication rate was 1.00% (CSF leak 0.17%; orbital injury 0.07%; hemorrhage requiring transfusion 0.76%). CSF leak was less likely to occur in the pediatric population (p = 0.05), whereas orbital injury was more likely to occur in children (p < 0.001). Examination of the impact of image guidance (IGS) was limited by study design.The incidence of major complications associated with ESS appears to have decreased since early reports over 10 years ago. There may be different complication rates in the pediatric population. Study design limitations did not allow for comprehensive assessment of IGS in the development of these complications. These data help to educate otolaryngologists and patients about complication rates in ESS in a modern context.

    View details for DOI 10.1002/alr.20101

    View details for Web of Science ID 000308925100007

    View details for PubMedID 22311839

  • Interrater reliability of endoscopic parameters following sinus surgery LARYNGOSCOPE Smith, T. L., Hwang, P. H., Murr, A. H., Lavigne, F., Koreck, A. 2012; 122 (1): 230-236

    Abstract

    To determine the interrater reliability of a set of postoperative endoscopic scoring parameters in patients with chronic rhinosinusitis who have undergone endoscopic sinus surgery (ESS).Prospective cohort with retrospective review.One hundred twenty video-endoscopic evaluations in 20 subjects recorded at 14, 30, and 45 days after ESS were scored in real time by the clinical investigators who performed the endoscopies and recorded the videos and retrospectively by an independent panel of four sinus surgeons who were blinded to all information. The scoring parameters included categoric grading for adhesion formation and middle turbinate position and continuous grading (visual analog scale) for degree of inflammation and crusting. Interrater reliability of the panel members was assessed using the Fleiss kappa test, bias index and prevalence index for categoric data, and the Shrout-Fleiss test for continuous data. The level of agreement between the panel and the real-time clinical investigator was also assessed.For categoric variables, strong agreement between raters on the panel was found for both middle turbinate position (kappa=0.499, prevalence index=0.925) and adhesions (kappa=0.364, prevalence index=0.829). For continuous data, good agreement between raters was found for both inflammation (reliability coefficient=0.554) and crusting (reliability coefficient=0.620). Real-time investigator scoring and panel scoring showed strong agreement.These results suggest that the endoscopic scoring parameters assessed (middle turbinate position, adhesions, inflammation, and crusting) have acceptable interexaminer reproducibility and are suitable for evaluating ESS outcomes in the postsurgical period.

    View details for DOI 10.1002/lary.22440

    View details for Web of Science ID 000298586300040

    View details for PubMedID 22095409

  • Xylitol Nasal Irrigation in the Management of Chronic Rhinosinusitis: A Pilot Study LARYNGOSCOPE Weissman, J. D., Fernandez, F., Hwang, P. H. 2011; 121 (11): 2468-2472

    Abstract

    To determine the tolerability of xylitol mixed with water as a nasal irrigant and to evaluate whether xylitol nasal irrigation results in symptomatic improvement of subjects with chronic rhinosinusitis.A prospective, randomized, double-blinded, controlled crossover pilot study.Twenty subjects were instructed to perform sequential 10-day courses of daily xylitol and saline irrigations in a randomized fashion, with a 3-day washout irrigation rest period at the start of each treatment arm. Collected data included patient characteristics, along with Sino-Nasal Outcome Test 20 (SNOT-20) and Visual Analog Scale (VAS) scores reported at the beginning and end of each irrigation course.Fifteen of the 20 subjects (75%) returned their SNOT-20 and VAS data for analysis. There was a significant reduction in SNOT-20 score during the xylitol phase of irrigation (mean drop of 2.43 points) as compared to the saline phase (mean increase of 3.93 points), indicating improved sinonasal symptoms (P = .0437). There was no difference in VAS scores. No patient stopped performing the irrigations owing to intolerance of the xylitol, although its sweet taste was not preferred by three subjects (21%). One patient reported transient stinging with xylitol.Xylitol in water is a well-tolerated agent for sinonasal irrigation. In the short term, xylitol irrigations result in greater improvement of symptoms of chronic rhinosinusitis as compared to saline irrigation.

    View details for DOI 10.1002/lary.22176

    View details for Web of Science ID 000296714800034

    View details for PubMedID 21994147

  • Novel effects of statins in enhancing efficacy of chemotherapy in vitro in nasopharyngeal carcinoma INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Wang, W., Le, W., Cho, D., Hwang, P. H., Upadhyay, D. 2011; 1 (4): 284-289

    Abstract

    Nasopharyngeal cancer (NPC) is a relatively uncommon malignant epithelial cancer seen worldwide. The treatment of NPC has evolved toward combined modality treatment with radiation therapy and chemotherapy. However, chemotherapeutic agents currently have a secondary role, due to their lack of efficacy as curative agents. Recent identification of a novel property of statin drugs raises a promising hope that concurrent use of statins may enhance the efficacy of single-drug chemotherapy in NPC. However, the effects of statins have not been studied before in NPC. In this in vitro study, we demonstrate a unique property of statins that can enhance the efficacy of cisplatin in NPC.Primary human NPC cells (CCL-30) were treated with statins and cisplatin concurrently, and the effects on cell proliferation, apoptosis, and cell colony formation were examined.Statins caused significant decrease in cell proliferation and viability in NPC. Statins also induced loss of cell attachment, change in cellular morphology, decrease in colony forming units, and loss of sphere formation in soft gel agar, which are the important properties of tumorigenicity in NPC. Furthermore, we found that the effects of statins occur by a mevalonate (MA)-mediated pathway in these cells.We demonstrate a unique property of statins that can enhance the antitumor effects of cisplatin in NPC. Statins may act as a relatively safe and cost effective chemoadjuvant agent in the treatment of NPC.

    View details for DOI 10.1002/alr.20039

    View details for Web of Science ID 000308922300010

    View details for PubMedID 22287433

  • Inhibition of Inflammatory Mediators: Role of Statins in Airway Inflammation OTOLARYNGOLOGY-HEAD AND NECK SURGERY Wang, W., Le, W., Ahuja, R., Cho, D., Hwang, P. H., Upadhyay, D. 2011; 144 (6): 982-987

    Abstract

    To determine if statins induce anti-inflammatory effects in upper airway inflammation. Mediators of innate and adaptive immunity regulate airway inflammation. Release of these mediators involves enzymatic conversion of polyunsaturated fatty acids into biologically active mediators, which can be blocked by statins. Although upper airway inflammation and chronic sinusitis occur in millions of patients with asthma worldwide, the anti-inflammatory effects of statins in upper airway inflammation have not been previously studied.Laboratory research.Tertiary referral center.Analysis of sinus tissues collected from patients with chronic rhinosinusitis revealed suppression of highly expressed inflammatory mediators in patients who were found to be on statins, suggesting that statins may induce anti-inflammatory effects. Therefore, the authors performed an in vitro study to determine if these anti-inflammatory effects were induced by statins. Cultured primary human airway epithelial cells were exposed to ambient air pollution particulates (PM) to trigger the inflammation, with and without statins, and the expression of inflammatory mediators was analyzed.The authors found that expression of CCL5, CCL11, and IL13RA was suppressed in patients on statins. In vitro exposure to PM enhanced the expression of these mediators, while pretreatment with statins completely blocked these effects. Furthermore, the effects of statins were blocked by inhibition of the statin pathway using isopentenyl-5-pyrophosphate. Statins did not have any significant effect on the viability of normal cells.Statins induce anti-inflammatory effects in human airway epithelial inflammation. Statins may play a role in the treatment and prevention of chronic rhinosinusitis and pulmonary exacerbation of obstructive airway diseases.

    View details for DOI 10.1177/0194599811400367

    View details for Web of Science ID 000293998800030

    View details for PubMedID 21493317

  • Correlation of Asymmetric Facial Growth with Deviated Nasal Septum LARYNGOSCOPE Kim, Y. M., Rha, K., Weissman, J. D., Hwang, P. H., Most, S. P. 2011; 121 (6): 1144-1148

    Abstract

    To evaluate the correlation between growth differences of the face and nasal septal deviation, and to evaluate whether developmental differences of the face have an effect on nontraumatic nasal septal deviation (DNS).Retrospective study.Twenty-five patients with DNS who underwent facial aesthetic surgery and had an ostiomeatal unit-computed tomography (OMU-CT) scan and photos for facial analysis were included in the study. Coronal views of the OMU-CT scan where the nasal septum was most severely deviated were selected and from which five parameters (angle of septal deviation [ASD], angle of nasal floor [ANF], angle of lateral nasal wall [ALW], angle of inferior turbinate [AIT], and width of IT [WIT]) were measured. Preoperative frontal views of the patients were analyzed by comparing the distances between the following points on both sides of the faces: midsagittal plane to Zygion (MSP-Zy), Glabella to Exocanthion (G-Ex), Exocanthion to Cheilion (Ex-Ch), and Zygion to Cheilion (Zy-Ch).The differences between the right and left MSP-Zy, G-Ex, and Ch-Zy distance were significantly associated with the direction of septal deviation. The difference between the right and left AIT and WIT were also significantly associated with the direction of septal deviation. Using bivariate correlation, it was found that the absolute difference between the right and left MSP-Zy, G-Ex, and WIT showed significant correlation with the amount of septal deviation.We demonstrate that there is a strong relationship between deviated nasal septum and facial growth asymmetry.

    View details for DOI 10.1002/lary.21785

    View details for Web of Science ID 000291259900004

    View details for PubMedID 21495046

  • Oral corticosteroid therapy in chronic rhinosinusitis without polyposis: a systematic review INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Lal, D., Hwang, P. H. 2011; 1 (2): 136-143

    Abstract

    Recognition of inflammation in the pathophysiology of chronic rhinosinusitis (CRS) has caused corticosteroid therapy in CRS to gain favor. A systematic evaluation of oral steroid use in CRS without nasal polyps (CRSsNP) has not been previously conducted. The objective of the study was to assess evidence on oral steroid therapy in CRSsNP, via a systematic literature review.Ovid and PubMed databases were searched for studies on oral steroid therapy in CRSsNP. Manuscripts were reviewed and graded by evidence-based medicine (EBM) level.A total of 33 studies met inclusion criteria; 30 on CRSsNP and 3 on allergic fungal sinusitis (AFS). CRSsNP studies did not include any randomized controlled trial (RCT) or any clinical study employing systemic corticosteroids alone. They included 20 reviews/expert opinions (Level 5) with differing recommendations, and 4 treatment guidelines (Level 4) with weak recommendations on use. Three studies, 2 retrospective (Level 4) and 1 prospective study (Level 3), used oral steroids in combination with antibiotics and nasal steroids. The multidrug regimen improved symptoms, radiologic findings, short-term relapses, nasal endoscopy, and cytokine pattern expression. An experimental study (Level 5) found oral steroids to reverse sinonasal tissue inflammation. Two studies in animal models (Level 5) found no benefit of adding systemic steroids to antibiotics. Three clinical AFS studies, 1 RCT (Level 1) and 2 prospective (Level 3), found oral steroids to benefit postoperative recurrence, endoscopy or computed tomography (CT).No study has employed systemic corticosteroids alone in treating CRSsNP. Evidence supporting oral steroid therapy in CRSsNP is mostly Level 4 or 5; there is lack of any RCT to support use.

    View details for DOI 10.1002/alr.20024

    View details for Web of Science ID 000308912300011

    View details for PubMedID 22287332

  • Systematic Review of Topical Vasoconstrictors in Endoscopic Sinus Surgery LARYNGOSCOPE Higgins, T. S., Hwang, P. H., Kingdom, T. T., Orlandi, R. R., Stammberger, H., Han, J. K. 2011; 121 (2): 422-432

    Abstract

    The objective of this study is to systematically review the literature and examine the safety for the use of topical vasoconstrictors in endoscopic sinus surgery.Systematic review clinical trials.A systematic literature search was performed in MEDLINE, EMBASE, The Cochrane Library, and National Guideline Clearinghouse, and references in the selected articles.The search criteria captured 42 manuscripts with relevant titles. A systematic review on the topical use of phenylephrine was found; however, no other systematic review, meta-analyses, or clinical guidelines were identified. Six randomized clinical trials or comparative studies, as well as multiple case reports and review articles were also identified. The literature supports the safety of oxymetazoline and epinephrine when used judiciously in carefully selected patients undergoing endoscopic sinonasal surgery; however, topical phenylephrine is not recommended because of its risk profile.In sinus or nasal surgery, topical vasoconstrictors should be used in a manner that minimizes the risk of cardiovascular morbidity.

    View details for DOI 10.1002/lary.21286

    View details for Web of Science ID 000287006400035

    View details for PubMedID 21271600

  • Safety and efficacy of a novel bioabsorbable, steroid-eluting sinus stent INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Murr, A. H., Smith, T. L., Hwang, P. H., Bhattacharyya, N., Lanier, B. J., Stambaugh, J. W., Mugglin, A. S. 2011; 1 (1): 23-32

    Abstract

    Inflammation/polyp recurrence, adhesions, and middle turbinate lateralization are causes of suboptimal outcomes following sinus surgery and lead to increased rates of revision. A bioabsorbable, drug-eluting stent was evaluated for its ability to preserve sinus patency by providing controlled steroid delivery to the sinus mucosa. The study objective was to assess safety and efficacy of a steroid-eluting sinus stent when used following functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis (CRS).Prospective, multicenter, randomized, double-blind clinical trial, enrolling 43 patients in 2 groups. One group (n = 38) used an intrapatient control design comparing drug-eluting to non-drug-eluting stents. The other group (n = 5) received bilateral drug-eluting stents to assess systemic safety. Endoscopic follow-up was performed for 60 days. Efficacy endpoints included assessment of inflammation, polyp formation, adhesions, and middle turbinate position.Stents were successfully deployed in all 86 sinuses. Compared to the control stent, the drug-eluting stent provided statistically significant reduction in inflammation at days 21 to 45 (p < 0.003), frequency of polyp formation (p = 0.0391), and frequency of significant adhesion (p = 0.0313). Reduced frequency of middle turbinate lateralization was also apparent though not statistically significant. No device-related adverse events occurred. Eluted steroid was unquantifiable systemically and there was no evidence of adrenal cortical suppression.This study demonstrates the safety and efficacy of a novel bioabsorbable, steroid-eluting stent for use in CRS patients. The steroid-eluting stent is effective in improving wound healing by preserving sinus patency, reducing inflammation, and minimizing adhesions via controlled local steroid delivery without measurable systemic exposure.

    View details for DOI 10.1002/alr.20020

    View details for Web of Science ID 000308911900005

    View details for PubMedID 22287304

  • Safety of a Preservative-Free Acidified Saline Nasal Spray A Randomized, Double-blind, Placebo-Controlled, Crossover Clinical Trial ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Ryan, W. R., Hwang, P. H. 2010; 136 (11): 1099-1103

    Abstract

    To determine the safety and tolerance of a buffered preservative-free acidified solution as an alternative to standard chemical preservatives to prevent microbial contamination of saline nasal spray.Randomized, double-blind, placebo-controlled, crossover clinical trial.Tertiary academic medical center.Healthy volunteers with no history or signs of sinonasal disease.Twenty volunteers used a buffered preservative-free acidified solution in a saline nasal spray and a benzalkonium chloride-containing saline nasal spray for 1 week each, separated by a 1-week washout period.At study enrollment and after using each nasal spray solution, participants completed a visual analog scale symptom questionnaire and the 20-Item Sino-Nasal Outcome Test and underwent nasal endoscopic examination, which was graded using a modified Lund-Kennedy scoring system. At the end of each test period, the contents of each nasal spray bottle were cultured for microorganism growth.All 20 participants completed the study. Four participants who developed upper respiratory tract illnesses during the study period were excluded from secondary analyses. No differences were observed in specific sinonasal symptoms or nasal endoscopy findings after use of either nasal spray. No nasal spray solutions from either group had any microorganism growth.In a short-term study with a small sample size, a preservative-free acidified solution seems to be safe and well tolerated, while maintaining sterility in a multiple-dose applicator without use of chemical preservatives.

    View details for Web of Science ID 000284231000009

    View details for PubMedID 21079163

  • Migration of regulatory T cells toward airway epithelial cells is impaired in chronic rhinosinusitis with nasal polyposis CLINICAL IMMUNOLOGY Kim, Y. M., Munoz, A., Hwang, P. H., Nadeau, K. C. 2010; 137 (1): 111-121

    Abstract

    The pathogenesis of chronic rhinosinusitis with nasal polyposis (CRSwNP) is still unclear. To evaluate the role of regulatory T cells (Treg) in the pathogenesis of nasal polyposis, we tested migration potential of Treg purified from subjects with CRSwNP, CRS without NP and controls. The nasal tissue expressions of FOXP3 were analyzed by means of RT-PCR and double immunohistochemistry. Chemotaxis assays were used to evaluate the migration potential of Treg onto bronchial epithelial cells and primary nasal epithelial cells, and toward chemokines. FOXP3(+)CD3(+) cells frequency and FOXP3 transcript expression in nasal tissue, and migration potentials of Treg toward airway epithelial cells and CCL1 were significantly lower in CRSwNP compared with other groups (P<0.05). These results indicate that migration potential of Treg is decreased in CRSwNP subjects, and this may be one of the reasons why tissue infiltration of Treg was decreased as seen in the immunohistochemistry of nasal polyps from CRSwNP subjects.

    View details for DOI 10.1016/j.clim.2010.05.013

    View details for Web of Science ID 000282204900013

    View details for PubMedID 20598643

  • Characteristics of Chloride Transport in Nasal Mucosa From Patients With Primary Ciliary Dyskinesia LARYNGOSCOPE Cho, D., Hwang, P. H., Illek, B. 2010; 120 (7): 1460-1464

    Abstract

    Primary ciliary dyskinesia (PCD) is an inherited disorder that produces lifelong difficulties with chronic airway inflammation. Little is known about the role of chronic airway inflammation on chloride ion transport properties in PCD. This study assessed the cyclic adenosine monophosphate (cAMP)-regulated chloride (Cl) ion transport properties of freshly excised nasal mucosa from PCD compared with normal and chronic rhinosinusitis (CRS).Electrophysiology study utilizing Ussing type hemi-chamber technique with three different types of nasal tissue (normal, CRS, PCD) obtained from patients during endoscopic surgery at a tertiary referral center.Nasal tissues were examined under short-circuit conditions, and gradient-driven Cl currents were continuously recorded. The cAMP elevating agonist (forskolin) was added to stimulate cystic fibrosis transmembrane conductance regulator-mediated Cl secretion. To prevent misinterpretation of flux measurement, Cl transport inhibitors were used at the end of all experiments. Basal Cl currents (I(Cl)) and changes in I(Cl) to forskolin (DeltaI(Cl)) were compared between normal, CRS, and PCD nasal tissues.Forskolin stimulated Cl currents across all different types of nasal epithelia. The Cl secretory response was effectively blocked by the Cl ion transport inhibitors. I(Cl) were significantly higher in normals (155.0 +/- 9.3 microA/cm(2)) compared to CRS (79.1 +/- 15.0 microA/cm(2)) and PCD (70.9 +/- 20.4 microA/cm(2)) (P = .005). DeltaI(Cl) in CRS (14.8 +/- 2.3 microA/cm(2)) and PCD (12.2 +/- 2.4 microA/cm(2)) were markedly diminished compared to normals (28.3 +/- 4.7 microA/cm(2)) (P = .024).PCD tissues were characterized by impaired I(Cl) and DeltaI(Cl). Both parameters were reduced by 54.3% and 56.9% in PCD when compared to normals.

    View details for DOI 10.1002/lary.20928

    View details for Web of Science ID 000279498500032

    View details for PubMedID 20564725

  • Outcomes After Middle Turbinate Resection: Revisiting a Controversial Topic LARYNGOSCOPE Soler, Z. M., Hwang, P. H., Mace, J., Smith, T. L. 2010; 120 (4): 832-837

    Abstract

    To evaluate differences in endoscopy exam, olfactory function, and quality-of-life (QOL) status after endoscopic sinus surgery (ESS) for patients with and without bilateral middle turbinate (BMT) resection.Open, prospective, multi-institutional cohort.Subjects completing enrollment interviews, computed tomography (CT), and endoscopy exam were asked to provide pre- and postoperative responses to the Smell Identification Test (SIT), Rhinosinusitis Disability Index (RSDI), Chronic Sinusitis Survey (CSS), and the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Bivariate and multivariate analyses were performed at the .05 alpha level.Forty-seven subjects with BMT resection were compared to 195 subjects without BMT resection with a mean follow-up of 17.4 months postoperatively. Patients with BMT resection were more likely to have asthma (P = .001), aspirin intolerance (P = .022), nasal polyposis (P = .025), and prior sinus surgery (P = .002). Patients with BMT resection had significantly higher baseline disease burden measured by endoscopy, CT, and SIT scores (P < .001). No significant differences in improvement were found in RSDI, CSS, or SF-36 scores between patients with BMT resection and those with BMT preservation (P > .05). Patients undergoing BMT resection were more likely to show improvements in mean endoscopy (-4.5 +/- 5.2 vs. -1.9 +/- 4.3; P = .005) and olfaction (5.3 +/- 10.8 vs. 1.3 +/- 7.6, P = .045) compared to those with BMT preservation.This investigation found no difference in QOL outcomes in patients with BMT preservation vs. resection. Patients undergoing BMT resection did, however, show greater improvements in endoscopy and SIT scores, which persisted after controlling for confounding factors.

    View details for DOI 10.1002/lary.20812

    View details for Web of Science ID 000276335100034

    View details for PubMedID 20232413

  • Nicotine induces resistance to chemotherapy in nasal epithelial cancer AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Shen, T., Le, W., Yee, A., Kamdar, O., Hwang, P. H., Upadhyay, D. 2010; 24 (2): E73-E77

    Abstract

    Epidemiological and clinical data implicate that in patients with cancer, continued smoking causes progression of cancer growth and resistance to therapy. The carcinogens possess the ability to block apoptosis, an important mechanism in the development of tumors and resistance to chemotherapy. We previously showed that nicotine enhances growth and proliferation in lung cancer. However, the effects of nicotine, a tobacco carcinogen that inhibits apoptosis, have not been studied before in nasal epithelial carcinoma (NC). In this study, we sought to determine the effects of nicotine on chemotherapy-induced apoptosis in human NC.Primary human NC cells were grown per protocol, treated with combination chemotherapy, and the apoptosis was assessed by TUNEL (terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling) and DNA fragmentation assays. The regulation of mitogen-activated protein kinase (MAPK) and protein kinase B (AKT) signal transduction pathway was examined by real time quantitative polymerized chain reaction, and immunofluorescent staining assays.Combination chemotherapy with cisplatin (35 microM) plus etoposide (20 microM) caused a significant increase in NC apoptosis compared with single agent alone, and nicotine, in part, inhibited chemotherapy-induced apoptosis in NC. Furthermore, nicotine induced activation of AKT and MAPK pathways, while inhibition of MAPK using U0126 and AKT by phosphatidylinositol 3-kinase inhibitor, LY294002, in part, blocked the antiapoptotic effects of nicotine against cisplatin and etoposide-induced apoptosis in NC.Nicotine inhibits chemotherapy-induced apoptosis in NC via the AKT and MAPK-mediated signaling pathways. We speculate that nicotine may play a role in oncogenesis and resistance to cancer therapy in NC.

    View details for DOI 10.2500/ajra.2010.24.3456

    View details for Web of Science ID 000292634800004

    View details for PubMedID 20338106

  • Integration of patient-specific paranasal sinus computed tomographic data into a virtual surgical environment AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Parikh, S. S., Chan, S., Agrawal, S. K., Hwang, P. H., Salisbury, C. M., Rafii, B. Y., Varma, G., Salisbury, K. J., Blevins, N. H. 2009; 23 (4): 442-447

    Abstract

    The advent of both high-resolution computed tomographic (CT) imaging and minimally invasive endoscopic techniques has led to revolutionary advances in sinus surgery. However, the rhinologist is left to make the conceptual jump between static cross-sectional images and the anatomy encountered intraoperatively. A three-dimensional (3D) visuo-haptic representation of the patient's anatomy may allow for enhanced preoperative planning and rehearsal, with the goal of improving outcomes, decreasing complications, and enhancing technical skills.We developed a novel method of automatically constructing 3D visuo-haptic models of patients' anatomy from preoperative CT scans for placement in a virtual surgical environment (VSE). State-of-the-art techniques were used to create a high-fidelity representation of salient bone and soft tissue anatomy and to enable manipulation of the virtual patient in a surgically meaningful manner. A modified haptic interface device drives a virtual endoscope that mimics the surgical configuration.The creation and manipulation of sinus anatomy from CT data appeared to provide a relevant means of exploring patient-specific anatomy. Unlike more traditional methods of interacting with multiplanar imaging data, our VSE provides the potential for a more intuitive experience that can replicate the views and access expected at surgery. The inclusion of tactile (haptic) feedback provides an additional dimension of realism.The incorporation of patient-specific clinical CT data into a virtual surgical environment holds the potential to offer the surgeon a novel means to prepare for rhinologic procedures and offer training to residents. An automated pathway for segmentation, reconstruction, and an intuitive interface for manipulation may enable rehearsal of planned procedures.

    View details for DOI 10.2500/ajra.2009.23.3335

    View details for Web of Science ID 000268797300016

    View details for PubMedID 19671264

  • A 51-Year-Old Woman With Acute Onset of Facial Pressure, Rhinorrhea, and Tooth Pain Review of Acute Rhinosinusitis JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hwang, P. H. 2009; 301 (17): 1798-1807

    Abstract

    Acute rhinosinusitis is a common ailment accounting for millions of office visits annually, including that of Mrs D, a 51-year-old woman presenting with 5 days of upper respiratory illness and facial pain. Her case is used to review the diagnosis and treatment of acute rhinosinusitis. Acute viral rhinosinusitis can be difficult to distinguish from acute bacterial rhinosinusitis, especially during the first 10 days of symptoms. Evidence-based clinical practice guidelines developed to guide diagnosis and treatment of acute viral and bacterial rhinosinusitis recommend that the diagnosis of acute rhinosinusitis be based on the presence of "cardinal symptoms" of purulent rhinorrhea and either facial pressure or nasal obstruction of less than 4 weeks' duration. Antibiotic treatment generally can be withheld during the first 10 days of symptoms for mild to moderate cases, given the likelihood of acute viral rhinosinusitis or of spontaneously resolving acute bacterial rhinosinusitis. After 10 days, the likelihood of acute bacterial rhinosinusitis increases, and initiation of antibiotic therapy is supported by practice guidelines. Complications of sinusitis, though rare, can be serious and require early recognition and treatment.

    View details for Web of Science ID 000265742500029

    View details for PubMedID 19336696

  • Effect of L-ascorbate on chloride transport in freshly excised sinonasal epithelia AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Cho, D., Hwang, P. H., Illek, B. 2009; 23 (3): 294-299

    Abstract

    Chronic rhinosinusitis (CRS) occurs at high frequency in patients with cystic fibrosis, suggesting that the cystic fibrosis transmembrane conductance regulator (CFTR) chloride (Cl) ion channel might be involved in the development of chronic sinusitis in the general population. CFTR Cl ion transport controls the hydration of mucosal surfaces and promotes effective mucociliary clearance. Altered ion transport and, hence, disrupted mucociliary function, could play a role in the pathogenesis of sinus disease. L-ascorbate is a metabolically active component of the nasal and tracheobronchial airway lining fluids and appears to serve as an important biological effector of CFTR-mediated chloride secretion. The purpose of this study was to determine the effects of L-ascorbate on Cl ion transport in freshly excised sinonasal epithelia from normal controls and patients with CRS.Four different types of sinonasal tissue (normal sinus mucosa, sinus mucosa from CRS, normal nasal mucosa, nasal mucosa from CRS) were obtained during endoscopic sinus surgery and mounted on sliders with open areas of 0.03-0.71 cm2 between Ussing hemichambers. Short-circuit current (Isc) was continuously recorded, and a serosa-to-mucosa-directed Cl gradient was applied to increase the electrochemical driving force.L-ascorbate (500 microM) stimulated Cl currents (DeltaI(Cl), microA/cm2) across sinonasal epithelia from normal and CRS patients. The Cl secretory response to L-ascorbate was effectively blocked by the Cl ion transport inhibitors glibenclamide and bumetanide. A maximal dose of L-ascorbate (at 1 mM) stimulated 53-70% of Cl currents elicited by the cAMP agonist forskolin. CRS sinonasal tissue was characterized by impaired Cl secretory responses to L-ascorbate that were reduced by 33% in sinus epithelial tissue and by 70% in nasal epithelial tissue when compared with normal subjects. In nasal epithelial tissue from normal subjects, Cl secretion was approximately twofold increased when compared with sinus epithelial tissue. In contrast, nasal versus sinus epithelial tissue from CRS patients showed no differences.Topical administration of L-ascorbate to freshly excised sinus and nasal mucosa enhances chloride secretion. Given that decreased CFTR-mediated Cl secretion may contribute to the development of CRS, L-ascorbate may offer potential as a therapeutic agent for the improvement of mucociliary clearance.

    View details for DOI 10.2500/ajra.2009.23.3316

    View details for Web of Science ID 000266387300011

    View details for PubMedID 19490804

  • Pathology Quiz Case 1 Glomangiopericytoma (sinonasal-type hemangiopericytoma [HPC]) ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Worden, B., Getz, A., Luo, R., Hwang, P. H. 2009; 135 (5): 520-?

    View details for Web of Science ID 000266207600018

    View details for PubMedID 19451477

  • Endoscopic approach to the infratemporal fossa for treatment of invasive fungal sinusitis AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Goyal, P., Leung, M., Hwang, P. H. 2009; 23 (1): 100-104

    Abstract

    Invasive fungal sinusitis is a progressive disease that can often extend beyond the nasal cavities and paranasal sinuses into surrounding soft tissue and bone. Aggressive antifungal therapy and surgical debridement are the mainstays of management. The pterygopalatine fossa and infratemporal fossa are two regions that are commonly involved in patients with invasive fungal sinusitis. When fungal disease extends to the infratemporal fossa, surgical debridement can be challenging. Traditionally, open approaches have been used for the management of disease in these areas. Advances in endoscopic skull base surgery may allow for less invasive approaches for the management of disease in the infratemporal fossa. This article describes a transnasal endoscopic approach to the infratemporal fossa for debridement of invasive fungal sinusitis.Patients with invasive fungal sinusitis extending into the infratemporal fossa were treated with endoscopic debridement. Records of these patients were reviewed.Endoscopic debridement was performed in four patients with infratemporal fossa extension of invasive fungal sinusitis. Responsible organisms included Aspergillus, Mucor, and Candida. Adequate access and excellent visualization of the infratemporal fossa were obtained in all patients. The endoscopic anatomy and surgical technique are presented.Endoscopic approaches have been used to manage a variety of disease processes that extend beyond the confines of the paranasal sinuses. Invasive fungal sinusitis disease with extension into the infratemporal fossa can be safely debrided via a transnasal endoscopic technique. The approach provides excellent visualization with low morbidity.

    View details for DOI 10.2500/ajra.2009.23.3270

    View details for Web of Science ID 000264995900020

    View details for PubMedID 19379622

  • Pathology Quiz Case Cholesterol granuloma (CG) of the left maxillary sinus ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Parikh, S., Mattoch, I. W., Kong, C., Hwang, P. H. 2008; 134 (11): 1233-1234

    View details for Web of Science ID 000261739700018

    View details for PubMedID 19015458

  • Results of endoscopic maxillary mega-antrostomy in recalcitrant maxillary sinusitis AMERICAN JOURNAL OF RHINOLOGY Cho, D., Hwang, P. H. 2008; 22 (6): 658-662

    Abstract

    In patients with chronically diseased maxillary sinuses, poor mucociliary clearance may result from long-standing inflammation or scarring from previous surgery. This subset of patients often has persistent sinus disease despite medical therapy and adequate antrostomy. Endoscopic maxillary mega-antrostomy (EMMA) is a mucosal sparing technique that facilitates mucus clearance and sinus irrigation in terminally dysfunctional maxillary sinuses. EMMA involves extending the antrostomy through the posterior half of the inferior turbinate down to the floor of the nose, creating a significantly enlarged antrostomy. This study describes our results of EMMA in recalcitrant maxillary sinusitis.A retrospective review was performed of patients who underwent EMMA for recalcitrant maxillary sinusitis between July 2005 and September 2007. We studied diagnoses, comorbid factors, clinical efficacy, revision rate, and complications.Twenty-eight patients (average age, 48 years) underwent 42 EMMAs for recalcitrant maxillary sinusitis. Average follow-up was 11 months. All patients had previous maxillary sinus surgery (mean = 2.3). Relevant comorbid factors included prior Caldwell-Luc or maxillofacial surgery (16/42), cystic fibrosis (11/42), asthma (11/42), and IgG deficiency (3/42). The most common symptoms reported were facial pain/pressure and purulent rhinorrhea. At the time of the most recent postoperative examination, 74% of patients reported complete resolution of symptoms while 26% reported partial symptomatic improvement. There were no complications and the revision rate was 0%.Maxillary sinuses that appear to be terminally diseased may be rehabilitated surgically without the need for surgical stripping. EMMA is an effective and safe treatment option for the management of recalcitrant maxillary sinus disease.

    View details for DOI 10.2500/ajr.2008.22.3248

    View details for Web of Science ID 000262205600019

    View details for PubMedID 19178809

  • The effects of retinoic acid on ciliary function of regenerated sinus mucosa AMERICAN JOURNAL OF RHINOLOGY Erickson, V. R., Antunes, M., Chen, B., Cohen, N. A., Hwang, P. H. 2008; 22 (3): 334-336

    Abstract

    Retinoic acid (RA) has been shown to enhance ciliary ultrastructure in regenerated sinus mucosa compared with controls. However, the functional status of the regenerated cilia has not been studied. Our objective was to evaluate the ciliary beat frequency (CBF) of regenerated sinus mucosa treated with topical RA in a rabbit model.Twelve rabbits underwent bilateral surgical stripping of the maxillary sinuses, followed by treatment with RA gel in the right side and an inert gel control in the left side. The rabbits were then killed at either 2 or 4 weeks, and CBF analysis of the regenerated mucosa was performed. Three unoperated rabbits were used to establish normative CBF data.Functional cilia were recovered from 11/12 RA-treated sinuses and 12/12 gel control sinuses. At 2 weeks postoperatively, the RA-treated sinuses showed an average CBF of 19.78 Hz, which was statistically comparable with the normal unoperated controls (p < 0.26). The inert gel-treated mucosa showed a CBF of 29.24 Hz, which was significantly elevated compared with normals (p < 0.05). At 4 weeks, ciliary activity persisted, but both RA-treated sinuses and gel controls showed elevated CBF compared with normals (p < 0.03).Topical RA placed in a demucosalized maxillary sinus yields functional cilia. RA appears to have a normalizing effect on CBF early in the mucosal wound healing process compared with control. This effect appears to be mitigated in later stages of wound healing. RA may be beneficial in enhancing morphological and functional aspects of regenerating cilia.

    View details for DOI 10.2500/ajr.2008.22.3176

    View details for Web of Science ID 000256132300022

    View details for PubMedID 18588770

  • Effects of sinus surgery on lung transplantation outcomes in cystic fibrosis AMERICAN JOURNAL OF RHINOLOGY Leung, M., Rachakonda, L., Weill, D., Hwang, P. H. 2008; 22 (2): 192-196

    Abstract

    In cystic fibrosis (CF) patients who are candidates for lung transplant, pretransplant sinus surgery has been advocated to avoid bacterial seeding of the transplanted lungs. This study reviews the 17-year experience of pretransplant sinus surgery among CF patients at a major transplant center.Retrospective chart review was performed in all CF patients who underwent heart-lung or lung transplantation at Stanford Medical Center between 1988 and 2005. Postoperative culture data from bronchoalveolar lavage (BAL) and sinus aspirates were evaluated, in addition to survival data.Eighty-seven CF transplant recipients underwent pretransplant sinus surgery; 87% (n=59/68) of patients showed recolonization of the lung grafts with Pseudomonas on BAL cultures. The median postoperative time to recolonization was 19 days. Bacterial floras cultured from sinuses were similar in type and prevalence as the floras cultured from BAL. When compared with published series of comparable cohorts in which pretransplant sinus surgery was not performed, there was no statistically significant difference in the prevalence of Pseudomonas recolonization. Times to recolonization also were similar. Survival rates in our cohort were similar to national survival rates for CF lung transplant recipients.Despite pretransplant sinus surgery, recolonization of lung grafts occurs commonly and rapidly with a spectrum of flora that mimics the sinus flora. Survival rates of CF patients who undergo prophylactic sinus surgery are similar to those from centers where prophylactic sinus surgery is not performed routinely. Pretransplant sinus surgery does not appear to prevent lung graft recolonization and is not associated with overall survival benefit.

    View details for Web of Science ID 000254801300019

    View details for PubMedID 18416979

  • Balloon catheter technology in sinus surgery AMERICAN JOURNAL OF RHINOLOGY Hwang, P. H. 2008; 22 (2): 105-105

    View details for Web of Science ID 000254801300001

    View details for PubMedID 18416962

  • Endoscopic septoplasty CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Getz, A. E., Hwang, P. H. 2008; 16 (1): 26-31

    Abstract

    Successful septoplasty involves accurate assessment of septal pathology and sound technique to avoid persistent symptoms and new complications. This review highlights endoscopic septoplasty techniques and instrumentation, as well as the indications for and advantages of endoscopic septoplasty as compared with traditional headlight septoplasty.Isolated lesions such as septal spurs and contact points may be better addressed with limited endoscopic techniques. Powered instrumentation has been utilized with reported success. Operative time and outcomes of endoscopic septoplasty are at least commensurate with, and at times superior to, traditional techniques.Endoscopic technology greatly enhances visualization during septoplasty. Discrete septal pathologies such as isolated deflection, spurs, perforations, and contact points can be addressed in a directed fashion. These advantages can be especially important in revision cases. Endoscopic technique in conjunction with video imaging is valuable for the education of residents and staff.

    View details for Web of Science ID 000270375100007

    View details for PubMedID 18197018

  • Wegener's granulomatosis: current trends in diagnosis and management. Current opinion in otolaryngology & head and neck surgery Erickson, V. R., Hwang, P. H. 2007; 15 (3): 170-176

    Abstract

    To provide an update on diagnostic methods and treatment options for Wegener's granulomatosis and to review common head and neck manifestations of the disease.Recent advances have been made in the systemic treatment of Wegener's granulomatosis, including the introduction of investigational immunosuppressive agents such as etanercept, leflunomide and deoxyspergualin. Surgical options remain indicated in selected complications of Wegener's granulomatosis such as saddle nose deformity and subglottic stenosis.Wegener's granulomatosis is an idiopathic, systemic vasculitis characterized by the formation of necrotizing granulomas of the respiratory tract in addition to focal or proliferative glomerulonephritis. Diagnosis is made by a combination of physical examination, laboratory studies and tissue biopsy. Head and neck manifestations are abundant and varied; common sites of involvement include the middle ear, nose and sinuses and subglottis. The mainstay of treatment remains systemic therapy using a combination of glucocorticoids and immunosuppressants. The otolaryngologist plays a key role in the diagnosis and treatment of head and neck complications of the disease. A surgical role exists for the management of nasal and sinus disease as well as laryngeal and tracheal disease.

    View details for PubMedID 17483685

  • Rehabilitation of surgically traumatized paranasal sinus mucosa using retinoic acid AMERICAN JOURNAL OF RHINOLOGY Leung, M., Hwang, P. H. 2007; 21 (3): 271-275

    Abstract

    Paranasal sinus mucosa that regenerates after surgical stripping is characterized by sparse, dysmorphic cilia. Although such dysfunctional mucosal changes are thought to be irreversible, the potential rehabilitation of deciliated mucosa by topical therapies has not been explored. This study evaluated the effect of topical retinoic acid (RA) in rehabilitating deciliated sinus mucosa that has regenerated after surgical stripping.Twelve New Zealand rabbits underwent bilateral maxillary sinus mucosal stripping and were allowed to remucosalize for 10 days. In the first treatment arm (n = 6), 0.01% RA was applied to the regenerated mucosa of the left maxillary sinus and an aqueous control was placed contralaterally. In the second treatment arm, the regenerated mucosa was surgically restripped bilaterally before applying RA and control. After 14 additional days, mucosa was harvested and examined by scanning electron microscopy for ciliary density, orientation, and morphology.In the first treatment arm, no significant differences in ciliary density, orientation, or morphology were noted between RA-treated sinuses and controls. In the second arm, RA-treated sinuses showed improved ciliary density, morphology, and orientation compared with controls.RA does not appear to significantly enhance ciliogenesis when applied after mucosal regeneration has occurred. However, if deciliated mucosa is restripped and allowed to regenerate in the presence of RA, ciliary ultrastructural features may be enhanced. RA may have therapeutic value in rehabilitating deciliated sinus mucosa when applied before mucociliary differentiation of regenerating mucosa.

    View details for DOI 10.2500/ajr.2007.21.3035

    View details for Web of Science ID 000247026000003

    View details for PubMedID 17621807

  • Infraorbital nerve surgical decompression for chronic infraorbital nerve hyperesthesia OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY Bailey, K., Ng, J. D., Hwang, P. H., Saulny, S. M., Holck, D. E., Rubin, P. A. 2007; 23 (1): 49-51

    Abstract

    To present three cases of chronic infraorbital nerve hyperesthesia relieved by surgical decompression of the infraorbital nerve.Retrospective chart review.We identified three cases of chronic hyperesthesia of the infraorbital nerve. Two cases were related to previous blunt orbital trauma, whereas the third was associated with a long-standing anophthalmic socket with numerous previous surgeries. In each case, patients had dramatic relief of infraorbital nerve hyperesthesia and pain after surgical decompression of the infraorbital nerve.Surgical decompression of the infraorbital nerve can provide significant symptomatic improvement in patients with chronic infraorbital nerve hyperesthesia secondary to nerve compression.

    View details for DOI 10.1097/IOP.0b013e31802dd3fc

    View details for Web of Science ID 000243950800012

    View details for PubMedID 17237691

  • Image-guided frontal trephination: A minimally invasive approach for hard-to-reach frontal sinus disease OTOLARYNGOLOGY-HEAD AND NECK SURGERY Zacharek, M. A., Fong, K. J., Hwang, P. H. 2006; 135 (4): 518-522

    Abstract

    Peripherally located frontal sinus pathology may be unreachable with standard endoscopic techniques. Patients with superiorly or laterally based lesions often undergo osteoplastic flap with or without obliteration. Image-guided frontal trephination (IGFT) can localize pathology and provide excellent exposure. We present 13 patients in whom this technique was applied.Medical records of 13 patients undergoing IGFT were retrospectively reviewed.The patients' mean age was 49.2 years, (range 14-79); follow-up time was 29.9 months (range 12-39). Indications for IGFT were superiorly or laterally based mucoceles (3), fibrous dysplasia or osteoma (3), type 4 frontal cells (3), and frontal recess stenosis or ossification (4). In five patients, IGFT was combined with endoscopic transethmoid frontal sinusotomy; eight patients were treated through a trephination approach, and three patients underwent trephination with unilateral frontal sinus obliteration. One patient required revision; all others remain symptom free.IGFT offers an attractive alternative to osteoplastic flap.

    View details for DOI 10.1016/j.otohns.2006.05.033

    View details for Web of Science ID 000241210500007

    View details for PubMedID 17011410

  • The utility of concurrent rhinoplasty and sinus surgery - A 2-team approach ARCHIVES OF FACIAL PLASTIC SURGERY Marcus, B., Patel, Z., Busquets, J., Hwang, P. H., Cook, T. A. 2006; 8 (4): 260-262

    Abstract

    To evaluate the safety and efficiency of and patient satisfaction with a 2-team approach for combined rhinoplasty and sinus surgery.We conducted a retrospective medical chart analysis of consecutive patients with sinus disease and functional nasal obstruction. Forty-four patients (29 women and 15 men; age range, 22-75 years) had severe nasal obstruction with chronic sinusitis and were found to have indications for this procedure. All patients were followed up for a minimum of 6 months after surgery. Patients completed a standardized questionnaire at the time of medical chart review, and 36 patients completed a telephone interview.All 44 patients underwent rhinoplasty with an endoscopic sinus procedure. Twenty-seven procedures (61%) were endonasal, whereas 17 (39%) were open rhinoplasty. Patients with internal nasal valve collapse underwent 28 butterfly grafts, 6 spreader grafts, and 8 batten grafts. The endoscopic sinus procedures consisted of maxillary antrostomy (30/44 [68%]) and ethmoidectomy (28/44 [63%]). Overall, 20 (65%) of 31 patients reported a postsurgical nasal airway that was significantly improved. Most sinus symptoms were resolved postoperatively, with 25 (71%) of 35 patients describing their improvement as significant. Thirty-two (92%) of 36 patients stated that they would recommend the concurrent procedure.Patients presenting with nasal obstruction and chronic sinusitis tolerated combined rhinoplasty and sinus procedures without added morbidity.

    View details for Web of Science ID 000239078900006

    View details for PubMedID 16847172

  • Retinoic acid improves ciliogenesis after surgery of the maxillary sinus in rabbits LARYNGOSCOPE Hwang, P. H., Chan, J. M. 2006; 116 (7): 1080-1085

    Abstract

    Retinoids have been shown to be important cofactors in regulating the differentiation and proliferation of ciliated epithelial cells of the respiratory tract. In particular, retinoic acid has been shown to enhance the regeneration of paranasal sinus mucosa. The objective of this study is to use scanning electron microscopy techniques to evaluate the effect of topical retinoic acid on mucosal wound healing in a rabbit model of maxillary sinus surgery. It is hypothesized that the application of topical retinoic acid will enhance ciliogenesis and improve the morphology of regenerated cilia compared with controls.Prospective multi-arm controlled animal trial.Eighteen New Zealand white rabbits underwent surgical opening of the maxillary sinuses through a midline incision. The rabbits were divided among four experimental groups: 1) mucosal stripping alone (stripped control), 2) stripping followed by topical application of an inert aqueous gel, 3) stripping followed by application of 0.01% retinoic acid in aqueous gel, and 4) no mucosal stripping and no topical treatment (nonstripped control). After 14 days, the medial wall of the maxillary sinus was harvested and examined by scanning electron microscopy at x2,000 and x5,000 magnification. The micrographs were then rated by a blinded review panel for ciliary density, orientation, and morphology.Mean scores for ciliary density, orientation, and morphology were all significantly higher for the retinoic acid treatment group compared with both the inert aqueous gel treatment group and the stripped control group (P=.004-.03 for all comparisons, Student's t test). Mean scores for the retinoic acid treatment group were numerically lower than the nonstripped control group but did not approach statistical significance for any parameter (P=.23-.31).In a rabbit model of maxillary sinus surgery, topically delivered retinoic acid enhances ciliogenesis. Qualitative assessment of ciliary density, orientation, and morphology shows improved healing in retinoic acid treated sinuses compared with both untreated control sinuses and aqueous gel treated sinuses.

    View details for DOI 10.1097/01.mlg.0000224352.50256.99

    View details for Web of Science ID 000238873800003

    View details for PubMedID 16826040

  • Perioperative care for advanced rhinology procedures OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Orlandi, R. R., Hwang, P. H. 2006; 39 (3): 463-?

    Abstract

    Successful outcomes in rhinologic surgery require careful endoscopic interventions, not only in the operating room, but also in the perioperative setting. In particular, meticulous postoperative care is essential to successful outcomes. This article reviews aspects of wound healing and perioperative care that can optimize surgical patency and clinical outcome.

    View details for DOI 10.1016/j.otc.2006.01.006

    View details for Web of Science ID 000238507600005

    View details for PubMedID 16757225

  • The utility of bipolar electrocautery in hereditary hemorrhagic telangiectasia OTOLARYNGOLOGY-HEAD AND NECK SURGERY Ghaheri, B. A., Fong, K. J., Hwang, P. H. 2006; 134 (6): 1006-1009

    Abstract

    The surgical treatment of epistaxis associated with hereditary hemorrhagic telangiectasia (HHT) is varied. Laser therapy is often inadequate for larger complex lesions. This study sought to determine if bipolar cautery can be effectively and safely used in treating HHT-associated epistaxis.Records from all patients with HHT treated surgically over 8 years were reviewed retrospectively. Outcomes or complications were noted in the clinic on follow-up evaluation.Twenty-seven patients with HHT who underwent surgical treatment of epistaxis were evaluated; 18 were treated with bipolar cautery. Forty-two separate bipolar treatments were performed. No new septal perforations or synechiae were noted. Twenty-two of 42 treatments were coupled with ancillary laser treatments. The bipolar was also used as the sole technique in 20 procedures.Bipolar electrocautery is a safe and effective tool for the intraoperative control of HHT-related epistaxis.Bipolar electrocautery may be used as an adjunct to laser techniques or as a stand-alone technique.C-4.

    View details for DOI 10.1016/j.otohns.2005.12.019

    View details for Web of Science ID 000238231900022

    View details for PubMedID 16730547

  • Intranasal deposition of nebulized saline: A radionuclide distribution study AMERICAN JOURNAL OF RHINOLOGY Hwang, P. H., Woo, R. J., Fong, K. J. 2006; 20 (3): 255-261

    Abstract

    Despite the popularity of various nasal sprays and nebulizers, there are limited data regarding the anatomic distribution of particles generated by these devices. This pilot study sought to characterize distribution patterns of nebulized and sprayed saline particles in normal subjects and postsurgical sinus patients.Fifteen subjects were studied in three trials: metered-dose nasal spray bottle versus vortex-propelled nebulizer in normal subjects, passive-diffusion nebulizer versus vortex nebulizer in normal subjects, and passive nebulizer versus vortex nebulizer in postsurgical sinus patients. Radiolabeled saline was administered, and nose, lungs, and stomach were imaged. Images were scored by four blinded reviewers for degree of penetration at nine anatomic subsites.Compared with spray bottle, the vortex nebulizer showed more focal intranasal distribution with reduced nasopharyngeal, pharyngeal, and gastric penetration in normal subjects. Three of five subjects showed probable frontal sinus penetration by vortex nebulizer, but no other sinus penetration was noted. No patients showed sinus penetration with the spray bottle. In a separate trial against the passive nebulizer, the vortex nebulizer again showed a greater tendency for sinus penetration in normal subjects, with three of five showing some degree of sphenoid penetration and one of five showing slight maxillary penetration. In contrast, no sinus penetration was observed with the passive nebulizer. In the postsurgical patient cohort, minimal sinus penetration was noted with either the vortex nebulizer or the passive nebulizer. Despite surgically patent sinuses, only one of five subjects showed any type of sinus penetration.The nebulizer and nasal spray devices tested in general showed limited penetration of the sinuses in both normal and postoperative patients. The device showing greatest promise for sinus penetration in normal patients was the vortex nebulizer, with an overall penetration rate in normal patients of 30% in the frontal, 30% in the sphenoid, and 10% in the maxillary. Understanding delivery patterns of topical therapies may be important in evaluating the efficacy of various topical treatment modalities.

    View details for DOI 10.2500/ajr.2006.20.2861

    View details for Web of Science ID 000238925900004

    View details for PubMedID 16871925

  • Endoscopic resection of sinonasal inverted papilloma: A meta-analysis OTOLARYNGOLOGY-HEAD AND NECK SURGERY Busquets, J. M., Hwang, P. H. 2006; 134 (3): 476-482

    Abstract

    Endoscopic resection has become an increasingly popular method of treating sinonasal inverted papillomas. The literature on endoscopic approaches to inverted papilloma consists primarily of relatively small case series (grade C evidence). This study aims to systematically review and integrate the available literature to objectively compare success rates of endoscopic versus nonendoscopic tumor resection techniques.A systematic review of the literature on resection of inverted papillomas.Comprehensive review of the English-language literature on resection of inverted papillomas was performed. The reports were subdivided into endoscopic approaches versus nonendoscopic approaches, applying strict inclusion and exclusion criteria. Our institution's experience with endoscopic treatment of inverted papilloma was also included. Studies from the era of endoscopic sinus surgery (1992-2004) formed a "contemporary" cohort and were compared with a "historical" cohort developed from the literature between 1970 and 1995.Thirty-two studies were included in the contemporary cohort, comprising 714 patients treated endoscopically and 346 patients treated nonendoscopically. Thirteen studies in the historical cohort yielded 692 patients treated nonendoscopically. There was a significantly lower recurrence rate in the contemporary cohort compared with the historical cohort (15% v 20%, P = 0.02). Within the contemporary cohort, endoscopically treated patients had significantly lower recurrences than nonendoscopically treated patients (12% v 20%, P < 0.01). Notably, the recurrence rate for nonendoscopically treated patients in the contemporary cohort was equivalent to that of the nonendoscopic patients in the historical cohort (20% v 19%, P = 0.78).A systematic review of the literature supports endoscopic resection as a favorable treatment option for most cases of sinonasal inverted papilloma. EBM rating: B-3a.

    View details for DOI 10.1016/j.otohns.2005.11.038

    View details for Web of Science ID 000235896400022

    View details for PubMedID 16500448

  • Surgical revision of the post-Caldwell-Luc maxillary sinus AMERICAN JOURNAL OF RHINOLOGY Han, J. K., Smith, T. L., Loehrl, T. A., Fong, K. J., Hwang, P. H. 2005; 19 (5): 478-482

    Abstract

    Endoscopic sinus surgeons are commonly faced with the management of patients with persistent maxillary sinusitis despite previous Caldwell-Luc surgery. Given the potential for altered mucociliary clearance in the post-Caldwell-Luc maxillary sinus, the optimal approach for surgical revision has not been well characterized. The objective of this study was to review our experience in endoscopic versus repeat Caldwell-Luc approaches in patients who have failed Caldwell-Luc surgery for chronic maxillary sinusitis.Retrospective chart review was performed on patients who had a history of a Caldwell-Luc procedure and who then underwent a surgical revision for persistent maxillary sinusitis at the Oregon Health and Science University and Medical College of Wisconsin between 1983 and 2002.Sixty-eight patients were identified, with a total of 156 revision procedures performed on 103 maxillary sinuses. Fifty-three percent of the sinuses underwent endoscopic maxillary antrostomy as the first surgical revision, while 47% underwent a revision Caldwell-Luc procedure. Sixty-seven percent of the sinuses in the revision endoscopic group had clinical resolution with a single surgical revision, and 60% of the sinuses in the revision Caldwell-Luc group had clinical improvement with one surgical revision (p = 0.46). The endoscopic group averaged 1.3+/-0.5 revision procedures per sinus to achieve clinical resolution, and the revision Caldwell-Luc group averaged 1.7+/-1.0 revision procedures per sinus (p = 0.3). Mean follow-up was 25 months.Endoscopic revision of the maxillary sinus yields comparable outcomes to repeat Caldwell-Luc procedure in patients with a history of previous failed Caldwell-Luc surgery. Endoscopic revision surgery is a viable alternative for surgical rehabilitation of the post-Caldwell-Luc maxillary sinus.

    View details for Web of Science ID 000232986700010

    View details for PubMedID 16270602

  • Surgical revision of the failed obliterated frontal sinus AMERICAN JOURNAL OF RHINOLOGY Hwang, P. H., Han, J. K., Bilstrom, E. J., Kingdom, T. T., Fong, K. J. 2005; 19 (5): 425-429

    Abstract

    Surgical revision of failed frontal sinus obliteration, traditionally, has been limited to repeat obliteration. However, endoscopic techniques may be successful in selected cases. We review our experience in surgical revision of failed frontal obliteration and propose a management algorithm.Retrospective chart review was performed over a 5-year period for patients who presented for surgical revision of a previously obliterated frontal sinus. Indications for surgery, radiological findings, and surgical approach were reviewed.Nineteen patients were identified, presenting an average of 9.7 years from the initial obliteration. Eighty-four percent (n = 16) were approached endoscopically and 16% (n = 3) were approached by revision obliteration. The mean follow-up was 25 months. In the endoscopic group, patients had either mucoceles in the inferomedial aspect of the frontal sinus or incomplete obliteration with persistent disease in the pneumatized frontal remnant. Eighty-one percent (13/16) were managed successfully with a single endoscopic procedure. Nineteen percent (3/16) had persistent disease requiring either a subsequent obliteration or Riedel ablation because of infected fat graft or frontal osteomyelitis. All patients who were managed successfully endoscopically remained free of disease with patent frontal sinusotomies throughout the follow-up period. The endoscopic failures required one to two additional external procedures to achieve disease resolution. In the revision obliteration group, all patients had mucoceles in either the lateral or the superior frontal sinus. All three patients had resolution of disease after a single procedure and remained free of disease throughout the follow-up period.Selected patients undergoing revision of frontal obliteration may benefit from endoscopic approaches. If disease is localized in the frontal recess or inferomedial frontal sinus, endoscopic management may be successful in the majority of patients. Superior or lateral frontal disease appears to be best approached externally. Patients undergoing endoscopic salvage should be counseled about the possible need for revision obliteration if disease persists.

    View details for Web of Science ID 000232986700001

    View details for PubMedID 16270593

  • Sagittal and coronal dimensions of the ethmoid roof: A radioanatomic study AMERICAN JOURNAL OF RHINOLOGY Zacharek, M. A., Han, J. K., Allen, R., Weissman, J. L., Hwang, P. H. 2005; 19 (4): 348-352

    Abstract

    Understanding the anatomy of the ethmoid roof is critical to safe surgical outcomes. Normative data regarding the height and slope of this region have been somewhat limited, derived primarily from cadaveric coronal computed tomography (CT) studies. With triplanar imaging programs, precise multidimensional measurements of the ethmoid roof are now possible. We present a radioanatomic study to characterize normative sagittal and coronal dimensions of the ethmoid roof.Bilateral measurements were taken in 100 consecutive sinus CT scans using ThinClient 3D software. In the sagittal plane, the height of the ethmoid roof was measured in quadrants at five equidistant points between the frontal beak and sphenoid face, referencing the nasal floor. In the coronal plane, the ethmoid roof was measured at three points at the level of the anterior ethmoid artery and at two points at the junction of the posterior ethmoid and sphenoid sinuses.When examined sagittally, the right side showed significantly lower skull base heights in the anterior ethmoid compared with the left side (59.0 mm versus 59.8 mm, p = 0.017; 53.7 mm versus 54.5 mm, p = 0.0004). Coronal measurements of the anterior ethmoid roof showed similar significant differences. The anterior ethmoid roof had greater asymmetries of height compared with the posterior ethmoid roof, which was fairly constant.This study provides numerical correlates to accepted concepts regarding the shape and slope of the ethmoid roof. Differences in height of the skull base between right and left sides, especially in the anterior ethmoid sinus, may be an important surgical consideration. The posterior ethmoid roof appears to be relatively constant and should serve as a reliable surgical landmark.

    View details for Web of Science ID 000231680000005

    View details for PubMedID 16171167

  • Surgical rhinology: recent advances and future directions OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Hwang, P. H. 2004; 37 (2): 489-?

    Abstract

    The discipline of rhinology is poised on the cusp of explosive growth in its cumulative body of knowledge. Advances in surgical technique, applied technology, and basic science over the past 2 decades have yielded significant benefits to both practitioner and patient. The future holds great promise for continued technical innovation, acquisition of new knowledge,and advances in the science of rhinology.

    View details for Web of Science ID 000221010200019

    View details for PubMedID 15064076

  • The office management of recalcitrant rhinosinusitis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Zacharek, M. A., Hwang, P. H., Fong, K. J. 2004; 37 (2): 365-?

    Abstract

    The patient referred to the otolaryngologist for the treatment of CRS has received many therapies for the condition. Newer therapies available focus on the anti-inflammatory therapies and local application of antimicrobial and antifungal agents to the sinus cavities. Much clinical work remains to be done to prove the efficacy of currently available treatments. The recent advances in the understanding of allergic and immune mechanisms may allow eventual intervention at the level of cytokines and other immunomodulators of inflammation. The complex cascade of interleukins and proinflammatory agents in CRS patients may some day allow "silver bullet" therapies in the properly selected patient. Until then, a systematic approach to the evaluation of these patients and management with the currently available treatment modalities may help relieve the symptoms in patients with CRS.

    View details for DOI 10.1016/S0030-6665(03)00170-1

    View details for Web of Science ID 000221010200011

    View details for PubMedID 15064068

  • Head and neck manifestations of Wegener's granulomatosis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Gubbels, S. P., Barkhuizen, A., Hwang, P. H. 2003; 36 (4): 685-?

    Abstract

    Wegener's granulomatosis is an idiopathic, granulomatous disease with the potential for multiple head and neck manifestations. The otolarygologist is an essential part of the multidisciplinary team involved in establishing the diagnosis and providing ongoing care for patients with Wegener's granulomatosis. Diagnostic difficulties abound in Wegener's granulomatosis, making repeat biopsies and the use of ANCA imperative. Medical therapy consisting of corticosteroids and immunosuppressive agents is the mainstay of treatment in Wegener's granulomatosis, whereas surgery is reserved for selected head and neck manifestations. With appropriate medical and surgical treatment, many patients living with Wegener's granulomatosis can enjoy a good quality of life.

    View details for DOI 10.1016/S0030-665(03)00023-9

    View details for Web of Science ID 000184209600010

    View details for PubMedID 14567060

  • Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery LARYNGOSCOPE Shiley, S. G., Limonadi, F., Delashaw, J. B., Barnwell, S. L., Andersen, P. E., Hwang, P. H., Wax, M. K. 2003; 113 (8): 1283-1288

    Abstract

    The incidence of cerebrospinal fluid (CSF) leak following trans-sphenoidal surgery ranges from 0.5% to 15.0%. Factors predicting which patients are likely to develop postoperative leaks and optimal management of these patients are poorly defined. The objective was to determine 1) the incidence of CSF leak following trans-sphenoidal surgery; 2) demographic or intraoperative factors associated with postoperative leaks; 3) techniques and efficacy of postoperative leak management at Oregon Health and Science University, (Portland, OR).Retrospective chart review.Two hundred thirty-five trans-sphenoidal surgeries were performed on 216 patients between 1994 and 2001. Follow-up data were available for 217 operations (92.3%) performed on 202 patients (93.5%).Postoperative CSF leaks occurred in 6.0% (13 of 217) of patients. Leaks were more common in the setting of revision surgery versus primary surgery (14.6% vs. 4.0%, P =.0096), nonadenomatous disease versus pituitary adenoma (15.8% vs. 5.1%, P =.059), or if an intraoperative leak occurred (12.7% vs. 2.7%, P =.004). However, on multivariate analysis, only the presence of intraoperative leak (P =.008) and nonadenomatous disease (P =.047) were found to be independently associated with postoperative CSF leak. Size of adenoma was not associated with occurrence of postoperative CSF leak (6.4% for microadenoma vs. 4.2% for macroadenoma) on both univariate and multivariate analysis. There were 13 postoperative CSF leaks: 2 resolved with lumbar drainage and 11 required operative management (three required multiple procedures). Of the three patients who required multiple operations, two had hospital courses complicated by meningitis and postinfectious hydrocephalus and ultimately required ventriculoperitoneal shunts. Endoscopic re-exploration was successful in 87.5% (7 of 8) of cases.Cerebrospinal fluid leaks following trans-sphenoidal surgery occurred in 6.0% of cases. Nonadenomatous disease and presence of an intraoperative leak were independent predictors of a postoperative leak. Endoscopic re-exploration combined with packing was an effective technique in managing uncomplicated postoperative leaks. In the setting of meningitis and postinfectious hydrocephalus, more invasive techniques such as ventriculoperitoneal shunt may be necessary.

    View details for Web of Science ID 000184790900002

    View details for PubMedID 12897546

  • Effects of topically applied biomaterials on paranasal sinus mucosal healing AMERICAN JOURNAL OF RHINOLOGY Maccabee, M. S., Trune, D. R., Hwang, P. H. 2003; 17 (4): 203-207

    Abstract

    Recently, nasal packing made of absorbable biomaterial has become increasingly popular. Although absorbable packs are effective for hemostasis, their impact on healing mucosa is unknown. Some have felt that a biocompatible sinus dressing actually may enhance healing, particularly in areas where the mucosa has been stripped. The aim of this study was to determine the effect of topical MeroGel and FloSeal on paranasal sinus mucosal healing in a rabbit model.Bilateral maxillary sinuses of 12 New Zealand white rabbits were surgically opened and stripped of mucosa. The left maxillary sinus of six rabbits had sterile saline-soaked MeroGel placed in the antrum, and the other six rabbits received FloSeal. The right maxillary sinuses of all 12 animals were stripped and otherwise untreated to serve as stripped controls. The animals were killed at 2 weeks and specimens were examined by light microscopy.MeroGel-treated mucosa showed extensive fibrosis of the basal lamina and lamina propria, complete loss of surface epithelium, and loss of the mucociliary blanket. There was minimal resorption of the MeroGel, and MeroGel fibers were frankly incorporated into the regenerated epithelium, associated with an exuberant lymphocytic infiltrate. FloSeal-treated mucosa showed similar fibrosis of the basal lamina and lamina propria with loss of the mucociliary blanket, although to a lesser degree than the MeroGel- treated group. FloSeal showed similar incorporation into the healed mucosa with lymphocytosis. Controls showed expected submucosal gland reduction, lamina propria fibrosis, and loss of cilia, but the lamina propria fibrosis seen in the MeroGel and FloSeal groups was markedly more prominent.In a rabbit model, MeroGel and FloSeal appear to increase reactionary fibrosis of healing mucosa. These agents also appear to be incompletely resorbed and grossly incorporated into healing tissue. Mucosal healing may be impaired by the application of these agents.

    View details for Web of Science ID 000185068000005

    View details for PubMedID 12962189

  • Paranasal sinus mucosal regeneration: The effect of topical retinoic acid AMERICAN JOURNAL OF RHINOLOGY Maccabee, M. S., Trune, D. R., Hwang, P. H. 2003; 17 (3): 133-137

    Abstract

    Paranasal sinus mucosa may suffer morphological and functional alterations as a result of surgical trauma. Mucosal stripping typically yields regenerated mucosa characterized by fibrosis, inflammatory infiltrate, and dysmorphic or absent cilia. The aim of this study was to determine the effect of topical retinoic acid (vitamin A) on regeneration of paranasal sinus mucosa.Both maxillary sinuses of 12 New Zealand white rabbits were surgically opened and stripped of mucosa. Six rabbits received 0.01% topical retinoic acid gel treatment to the stripped left maxillary sinus (low concentration group). The remaining six rabbits received 0.025% topical retinoic acid gel to the stripped left maxillary sinus (high concentration group). The stripped right maxillary sinus of all 12 rabbits served as the operated, untreated control to reflect the normal healing process. Six other animals served as unoperated controls. The sinus mucosa was examined by light microscopy after 14 days.Untreated regenerated mucosa showed expected changes of submucosal gland loss, basal lamina and lamina propria fibrosis, cellular atypia, and loss of cilia. Topical retinoic acid treatment appeared to result in better mucosal regeneration marked by less cellular atypia and fibrosis. Although the regenerated mucosa was still grossly abnormal, the degree of ciliary loss and cellular derangement was reduced. The lower-concentration retinoic acid group had more favorable morphology than the higher-concentration retinoic acid group, and both were improved when compared with no treatment.In a rabbit model, topical vitamin A in the form of retinoic acid gel appears to enhance regeneration of ciliated paranasal sinus mucosa. This preliminary study suggests that topical retinoids may have applicability in promoting sinus wound healing.

    View details for Web of Science ID 000183813700003

    View details for PubMedID 12862400

  • Radiologic correlates of symptom-based diagnostic criteria for chronic rhinosinusitis OTOLARYNGOLOGY-HEAD AND NECK SURGERY Hwang, P. H., Irwin, S. B., Griest, S. E., Caro, J. E., Nesbit, G. M. 2003; 128 (4): 489-496

    Abstract

    In 1997, the Task Force on Rhinosinusitis (TFR) set forth symptom-based diagnostic guidelines for chronic rhinosinusitis (CRS). In the present study, we examined radiologic correlates of the TFR diagnostic criteria for rhinosinusitis.One hundred twenty-five consecutive patients undergoing computed tomography (CT) scans of the sinuses were studied at Oregon Health and Science University. Patients were evaluated prospectively with a questionnaire based on the TFR criteria, and their CT scans were graded according to the Lund-Mackay scoring system.Of the 125 patients, 115 met the symptom criteria for CRS. However, 40 of 115 had negative scans (Lund-McKay score, 0) despite meeting the diagnostic criteria for rhinosinusitis. Of 115, 75 had positive scans (Lund-McKay score, >1). Of the 10 patients who had negative diagnoses for rhinosinusitis, 9 had a positive CT scan. The Kappa coefficient was -0.103 (+/-95% confidence interval, -0.201 to -0.004), indicating poor agreement between CRS positivity and CT positivity. The sensitivity of TFR criteria for detecting a positive scan was 89%, but the specificity was poor at only 2%.Based on these pilot data, it appears that the specificity and predictive value of the current TFR criteria may not be adequate to serve as a diagnostic standard for rhinosinusitis. Additional validating data may provide guidance for improving the sensitivity and specificity of symptom-based diagnostic instruments for rhinosinusitis.

    View details for DOI 10.1016/mhn.2003.95

    View details for Web of Science ID 000182346200007

    View details for PubMedID 12707650

  • Contemporary use of image-guided systems. Current opinion in otolaryngology & head and neck surgery Han, J. K., Hwang, P. H., Smith, T. L. 2003; 11 (1): 33-36

    Abstract

    Technologic advancements in radiographic imaging and interactive computers have allowed image-guided systems to be developed, which have been used to characterize surgical anatomy with greater accuracy and detail. Early generations of image-guided systems were difficult to use; however, recent modifications have allowed it to become more user friendly and less cumbersome. As a result, the application of image-guided systems has expanded and its use has become more frequent. Two major designs, optical and electromagnetic, have been used. Although most image-guided systems use computed tomography digital images, magnetic resonance image-based image-guided systems serve a unique and useful purpose. Future directions for image-guided surgery include smaller flexible instrumentation and simplified registration. As image-guided systems continue to evolve, they will enable otolaryngologist to broaden the horizon of minimally invasive techniques and operations.

    View details for PubMedID 14515099

  • Outpatient intravenous antibiotics for chronic rhinosinusitis LARYNGOSCOPE Gross, N. D., McInnes, R. J., Hwang, P. H. 2002; 112 (10): 1758-1761

    Abstract

    Peripherally inserted central catheter (PICC) lines have greatly facilitated the use of intravenous antibiotics in outpatient medical practice. Otolaryngologic applications for home intravenous therapy through PICC lines have not been well characterized to date. The purpose of the study is to describe indications and complications related to outpatient intravenous antibiotic therapy in patients with chronic rhinosinusitis.Retrospective cohort study.Chart review of patients with chronic rhinosinusitis who were treated at an academic rhinology practice with outpatient intravenous antibiotics over a 3-year period. RESULTS Fourteen patients receiving, in all, 16 courses of intravenous antibiotic therapy through PICC line were identified. The average patient age was 51 years (age range, 36-74 y). The primary indication for intravenous antibiotic use was the treatment of resistant pathogens (50%). The most common organisms treated were, and. Other indications included gastrointestinal intolerance of oral antibiotics and extranasal complications of sinusitis. Eighty-eight percent of patients (14 of 16) were able to complete the entire prescribed course of therapy. Three (19%) catheter-related complications occurred, including thrombophlebitis and deep venous thrombosis. All three complications required removal of the PICC line; one of these patients underwent successful reinsertion of a second catheter and completion of treatment.Peripherally inserted central catheter line delivery of home intravenous antibiotics can be a well-tolerated adjunct to surgery in the outpatient treatment of chronic rhinosinusitis. Resistant infections, intolerance to oral antimicrobials, and extranasal complications of sinusitis are indications for PICC line therapy. Catheter-related complications can be significant and must be considered in patient selection.

    View details for Web of Science ID 000178590500009

    View details for PubMedID 12368610

  • Headset-related sensory and motor neuropathies in image-guided sinus surgery ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Hwang, P. H., Maccabee, M., Lindgren, J. A. 2002; 128 (5): 589-591

    Abstract

    Complications related to the use of image-guided systems in sinus surgery are fortunately rare. We report a case series of 6 patients who experienced facial neuropathies (both sensory and motor) related to the use of a headset for electromagnetic-based image-guided surgery. The auriculotemporal nerve was the most common sensory nerve involved, and the buccal branch of the facial nerve was implicated in a case of motor weakness. The cause of the complication appears to be a pressure neuropathy caused by a tight-fitting headset against the external auditory meatus and temporomandibular joint. Additional risk factors for headset-related neuropathy may relate to body habitus, length of surgical procedure, and patient positioning. All patients' neuropathies resolved completely without intervention. Headset-related complications appear to be uncommon but may be an important consideration in counseling patients who are candidates for image-guided sinus surgery.

    View details for Web of Science ID 000175492500017

    View details for PubMedID 12003594

  • Medical therapy of acute and chronic frontal rhinosinusitis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Maccabee, M., Hwang, P. H. 2001; 34 (1): 41-?

    Abstract

    Despite innovations in surgical treatment of frontal sinus disease, medical therapy continues to be important. Preoperative, perioperative, and postoperative considerations are discussed. Diagnostic criteria, microbiology, and complications associated with frontal rhinosinusitis are also reviewed.

    View details for Web of Science ID 000168611200004

    View details for PubMedID 11344060

  • The five year experience with endoscopic trans-septal frontal sinusotomy OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Lanza, D. C., McLaughlin, R. B., Hwang, P. H. 2001; 34 (1): 139-?

    Abstract

    Endoscopic trans-septal frontal sinusotomy (TSFS) represents a unique surgical approach to the floor of the frontal sinus. Although the final result can have similarities to the modified Lothrop procedure in that the intersinus septum may be drilled out, endoscopic TSFS represents a novel approach that can be valuable in patients with certain anatomic configurations. Endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist to augment treatment of refractory frontal sinus disease. This procedure is best considered for patients with favorable anatomy who have significant frontal sinus disease and cannot be managed adequately through an endoscopic frontal sinusotomy.

    View details for Web of Science ID 000168611200013

    View details for PubMedID 11344069

  • Applications of in situ hybridization techniques in the diagnosis of chronic sinusitis AMERICAN JOURNAL OF RHINOLOGY Hwang, P. H., Montone, K. T., Gannon, F. H., Senior, B. A., Lanza, D. C., Kennedy, D. W. 1999; 13 (5): 335-338

    Abstract

    The clinical significance of positive bacterial cultures in chronic sinusitis is often difficult to assess. Contaminants from surface colonization of the sinus mucosa may be difficult to distinguish from true intramucosal or bone involvement. Furthermore, tissue Gram stains are frequently unable to demonstrate the presence of bacteria in tissue despite endoscopic evidence of active sinusitis. In situ hybridization (ISH) techniques using bacterial rRNA probes were applied to evaluate the presence of intramucosal and intraosseous bacteria in chronic sinusitis surgical specimens. A total of 22 specimens of chronically inflamed human ethmoid bone were evaluated by ISH and by Gram stain. In three specimens, ISH identified bacterial rRNA within sinus mucosa and mucin. Notably, in these three ISH-positive specimens, Gram stain was negative in two. No specimen showed evidence of bacterial rRNA within bone. These preliminary results suggest that in situ hybridization may be a useful adjunct to current methods of detecting microorganisms within chronically infected sinus tissue.

    View details for Web of Science ID 000083865900001

    View details for PubMedID 10582109

  • Endoscopic trans-septal frontal sinusotomy: The rationale and results of an alternative technique AMERICAN JOURNAL OF RHINOLOGY McLaughlin, R. B., Hwang, P. H., Lanza, D. C. 1999; 13 (4): 279-287

    Abstract

    Endoscopic transseptal frontal sinusotomy (TSFS) represents an alternate approach to surgical treatment of chronic frontal sinus disease that is refractory to traditional modes of medical and surgical therapy. We retrospectively reviewed our experience with endoscopic TSFS from 1995-1997. Twenty-one procedures were performed through a transseptal approach. One patient was excluded for failure to follow-up, for a total of 20 procedures. Patients were followed with serial endoscopic examinations and a telephone questionnaire with a mean follow-up of 12 months (Range 1-24 months) and 16 months (range 5-31), respectively. The primary indication for surgery was frontal recess stenosis after previous endoscopic frontal sinusotomy in 17/20 (85%). Three patients were considered poor candidates for a primary endoscopic frontal sinusotomy. Patency was maintained in all patients during the follow-up period. A diameter of greater than 3 mm was confirmed by passage of a curved suction in 19/20 (95%). Of the 19 patients that were evaluated via a telephone questionnaire, 17 patients (89.5%) reported some degree of improvement in their nasal/sinus symptoms, and 12/18 patients (67%) felt the frequency of medication requirements was less than that before undergoing endoscopic TSFS. We conclude that endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist, to augment treatment of refractory frontal sinus disease. This procedure seems especially suited for revision surgery in those patients with acquired frontal sinus stenosis. In revision operations with distorted anatomical landmarks, localization of the frontal sinus may be improved with the aid of 3-dimensional computer assisted localization systems. Unlike traditional frontal sinus obliteration, endoscopic TSFS does not preclude radiographic assessment postoperatively, and allows for endoscopic evaluation of the frontal sinus in the office setting.

    View details for Web of Science ID 000082368600005

    View details for PubMedID 10485014

  • Facial nerve dysfunction associated with cystic lesions of the mastoid OTOLARYNGOLOGY-HEAD AND NECK SURGERY Hwang, P. H., Jackler, R. K. 1998; 119 (6): 668-672

    View details for Web of Science ID 000077409400022

    View details for PubMedID 9852546

  • Correction of the twisted nose deformity: A surgical algorithm using the external rhinoplasty approach AMERICAN JOURNAL OF RHINOLOGY Hwang, P. H., Maas, C. S. 1998; 12 (3): 213-220

    Abstract

    Successful correction of the twisted nose is challenging due to the complex nature of the underlying anatomic deformity. Although the literature has in general supported endonasal rhinoplasty techniques for the twisted nose, we propose a surgical algorithm using the external rhinoplasty approach. The algorithm offer a stepwise, structured method that is adaptable to individual variations in anatomic deformity. The advantages and relative disadvantages of the external rhinoplasty approach are discussed, and a clinical experience of 30 patients is reviewed. Application of the external rhinoplasty algorithm in correction of the twisted nose can yield consistently satisfactory functional and aesthetic results.

    View details for Web of Science ID 000074454000011

    View details for PubMedID 9653481

  • Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis LARYNGOSCOPE Kennedy, D. W., Senior, B. A., Gannon, F. H., Montone, K. T., Hwang, P., Lanza, D. C. 1998; 108 (4): 502-507

    Abstract

    Mucosal changes have been well described in chronic sinusitis, yet little is known about the underlying bone, despite clinical and experimental evidence suggesting that bone may be involved in chronic sinusitis. Techniques of undecalcified bone analysis were used for detailed histologic examination of ethmoid bone in chronic sinusitis compared with controls. Bone synthesis, resorption, and inflammatory cell presence were specifically assessed. Additionally, histomorphometry techniques were used to determine ethmoid bone physiology in individuals undergoing surgery for chronic sinusitis. Overall, individuals undergoing surgery for chronic sinusitis were found to have evidence of marked acceleration in bone physiology with histologic changes including new bone formation, fibrosis, and presence of inflammatory cells. These findings are compared with osteomyelitis in long bone and the jaw. The suggestion that underlying bone may serve as a catalyst for chronic sinusitis is supported and implications for therapy are discussed.

    View details for Web of Science ID 000072939100008

    View details for PubMedID 9546260

  • Lipoid meningitis due to aseptic necrosis of a free fat graft placed during neurotologic surgery LARYNGOSCOPE Hwang, P. H., Jackler, R. K. 1996; 106 (12): 1482-1486

    Abstract

    We present two unusual cases of aseptic postoperative lipoid meningitis resulting from necrosis of a free fat graft placed into a skull base craniotomy defect. Two patients underwent translabyrinthine resection of acoustic neuroma and received abdominal fat grafts to ablate the surgical defect. Both patients presented postoperatively with persistent cerebrospinal fluid (CSF) wound leak and severe headache. Computed tomography demonstrated hydrocephalus and widely dispersed intracranial fat droplets throughout the CSF circulation. Both patients ultimately required CSF diversion for management of persistent communicating hydrocephalus. The clinical and radiographic correlates of lipocephalus and lipoid meningitis are presented, and a review of free fat graft physiology is discussed.

    View details for Web of Science ID A1996VX21200007

    View details for PubMedID 8948607

  • Pediatric penetrating keratoplasty. Seminars in ophthalmology Hwang, D. G., Hwang, P. H. 1991; 6 (4): 212-218

    View details for PubMedID 10149522

  • COLLAGEN SHIELD ENHANCEMENT OF TOPICAL DEXAMETHASONE PENETRATION ARCHIVES OF OPHTHALMOLOGY Hwang, D. G., STERN, W. H., Hwang, P. H., MACGOWANSMITH, L. A. 1989; 107 (9): 1375-1380

    Abstract

    Collagen corneal shields were investigated as a vehicle for enhancing the ocular penetration of topical 0.1% dexamethasone alcohol in rabbit eyes. Four protocols were compared: a single dexamethasone drop, hourly drops, a 24-hour collagen shield presoaked in 0.1% dexamethasone, and a presoaked collagen shield followed by hourly drops. Dexamethasone concentrations in the cornea, aqueous, iris, and vitreous were measured by radioassay at six time intervals, and cumulative drug delivery over 6 hours was calculated for each tissue. Treatment with a presoaked collagen shield plus hourly drops resulted in peak and cumulative drug delivery to the cornea, aqueous, iris, and vitreous that was twofold to fourfold higher than delivery achieved with hourly drops alone. A presoaked shield by itself yielded equivalent or superior peak and cumulative drug delivery compared with a regimen of hourly drops. Collagen shields significantly enhance topical dexamethasone penetration and may be useful for maximizing the intraocular delivery of dexamethasone and for decreasing the required frequency of topical dexamethasone administration.

    View details for Web of Science ID A1989AQ16700031

    View details for PubMedID 2783071

Conference Proceedings


  • Interrater agreement of nasal endoscopy for chronic rhinosinusitis Raithatha, R., Anand, V. K., Mace, J. C., Smith, T. L., Schaberg, M. R., Nyquist, G. G., Hwang, P. H., Senior, B. A., Stankiewicz, J. A., Tabaee, A. WILEY-BLACKWELL. 2012: 144-150

    Abstract

    Nasal endoscopy is a routine, important diagnostic tool in the evaluation of chronic rhinosinusitis (CRS). Although the procedure is ideally "objective," the subjective nature of endoscopy interpretation and lack of standardization are potential limitations. The goal of this study was to examine the interrater agreement of various categories of nasal endoscopy findings in patients undergoing evaluation for CRS.Fourteen patients (28 sides) with CRS underwent clinical evaluation, SNOT-22, sinus computed tomography (CT), and digital video nasal endoscopy. Five academic rhinologists blindly reviewed the endoscopies for structural anatomic issues, inflammatory rhinosinusitis findings, and atypical lesions. Statistical comparison of the endoscopy interpretations was performed using the unweighted Fleiss' kappa statistic (K(f) ).The mean Lund-Mackay CT scan score was 7.8 (standard deviation [SD] 4.9) and the mean SNOT-22 score was 35.8 (SD 22.7). Significant variability was noted among the raters with respect to the various categories of nasal endoscopy findings. The overall levels of interrater agreement for the various categories were as follows: "almost perfect" for atypical lesions (K(f) = 0.912); "substantial" for nasal polyps (K(f) = 0.693); "moderate" for nasal discharge (K(f) = 0.422) and mucosal inflammatory changes of the middle turbinate (K(f) = 0.413); and "fair" for edema of the middle meatus (K(f) = 0.214), obstruction by nasal septum deviation (K(f) = 0.240), and obstruction by the middle turbinate (K(f) = 0.276).Significant variability was noted in the interrater agreement for nasal endoscopy findings in this study, with relatively limited agreement on some of the key findings of the procedure. Additional investigation and standardization of nasal endoscopy interpretation is required to improve the clinical utility of the procedure.

    View details for DOI 10.1002/alr.21009

    View details for Web of Science ID 000308926000011

    View details for PubMedID 22253129

  • The effectiveness of preemptive sphenopalatine ganglion block on postoperative pain and functional outcomes after functional endoscopic sinus surgery Cho, D., Drover, D. R., Nekhendzy, V., Butwick, A. J., Collins, J., Hwang, P. H. WILEY-BLACKWELL. 2011: 212-218

    Abstract

    The sphenopalatine ganglion block (SPGB) with local anesthetic is used to treat facial pain and headache of various etiologies; it has been widely used during functional endoscopic sinus surgery (FESS). The purpose of this study was to investigate whether preemptive SPGB may positively impact postoperative pain and functional outcomes after FESS.A prospective, double-blind, randomized, placebo-controlled study was performed. A total of 60 patients (18-70 years), undergoing general anesthesia for bilateral FESS, were randomly assigned to receive SPGB with either 2 mL 0.25% bupivacaine with epinephrine 1:100,000 (BP, treatment group) or normal saline (NS, control group). SPGB was performed preemptively 10 minutes before the start of surgery. Preoperative and postoperative (day 0, day 7, and day 30) visual analog pain scale, Sino-Nasal Outcome Test (SNOT-20), computed tomography (CT) and endoscopic scores were compared between the 2 groups.A total of 29 patients were enrolled in BP, and 27 were enrolled in NS. Three patients withdrew from the study, and 1 was withdrawn by the investigator due to severe hypertension after induction of anesthesia. There were no differences in patient demographic characteristics between the study groups. On day 7, the mean visual analog pain scales were 1.12 ± 0.3 in NS and 0.48 ± 0.23 in BP (p = 0.053). There were no statistical differences in other outcome measures (SNOT-20, CT and endoscopic scores) between the 2 groups.A limited trend toward reduced postoperative pain after FESS was noted with bupivacaine compared to saline, but statistical significance was not achieved. Preemptive SPGB may offer sinonasal symptomatic benefits for patients undergoing FESS, but larger studies are warranted.

    View details for DOI 10.1002/alr.20040

    View details for Web of Science ID 000308912700014

    View details for PubMedID 22287376

  • Correlations Between Symptoms, Nasal Endoscopy, and In-Office Computed Tomography in Post-Surgical Chronic Rhinosinusitis Patients Ryan, W. R., Ramachandra, T., Hwang, P. H. WILEY-BLACKWELL. 2011: 674-678

    Abstract

    To determine correlations between symptoms, nasal endoscopy findings, and computed tomography (CT) scan findings in post-surgical chronic rhinosinusitis (CRS) patients.Cross-sectional.A total of 51 CRS patients who had undergone endoscopic sinus surgery (ESS) completed symptom questionnaires, underwent endoscopy, and received an in-office sinus CT scan during one clinic visit. For metrics, we used the Sinonasal Outcomes Test-20 (SNOT-20) questionnaire, visual analog symptom scale (VAS), Lund-Kennedy endoscopy scoring scale, and Lund-MacKay (LM) CT scoring scale. We determined Pearson correlation coefficients, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) between scores for symptoms, endoscopy, and CT.The SNOT-20 score and most VAS symptoms had poor correlation coefficients with both endoscopy and CT scores (0.03-0.24). Nasal drainage of pus, nasal congestion, and impaired sense of smell had moderate correlation coefficients with endoscopy and CT (0.24-0.42). Endoscopy had a strong correlation coefficient with CT (0.76). Drainage, edema, and polyps had strong correlation coefficients with CT (0.80, 0.69, and 0.49, respectively). Endoscopy had a PPV of 92.5% and NPV of 45.5% for detecting an abnormal sinus CT (LM score ?1).In post-ESS CRS patients, most symptoms do not correlate well with either endoscopy or CT findings. Endoscopy and CT scores correlate well. Abnormal endoscopy findings have the ability to confidently rule in the presence of CT opacification, thus validating the importance of endoscopy in clinical decision making. However, a normal endoscopy cannot assure a normal CT. Thus, symptoms, endoscopy, and CT are complementary in the evaluation of the post-ESS CRS patient.

    View details for DOI 10.1002/lary.21394

    View details for Web of Science ID 000287789400047

    View details for PubMedID 21305550

  • Acid and base secretion in freshly excised nasal tissue from cystic fibrosis patients with Delta F508 mutation Cho, D., Hwang, P. H., Illek, B., Fischer, H. WILEY-BLACKWELL. 2011: 123-127

    Abstract

    Cystic fibrosis (CF) is caused by a misfunctional CF transmembrane conductance regulator (CFTR) protein, which is believed to contributes to the regulation of the airway surface liquid (ASL) pH. This study investigated acid and base secretion in freshly excised human nasal tissues from CF patients homozygous for the ?F508 mutation.Human nasal mucosa was collected during sinus surgery and investigated in Ussing chambers. Mucosal equilibrium pH values and rate of acid and base secretion were determined using the pH-stat technique.The equilibrium pH of nasal epithelia from ?F508 CF patients with chronic rhinosinusitis (CRS) was pH = 7.08 ± 0.09 and was significantly lower compared to nasal epithelia from CRS patients without CF (pH = 7.33 ± 0.06) and normal subjects (pH = 7.34 ± 0.08, n = 6). The rate of base secretion in CF nasal tissues was 11.8 ± 2.4 nmol?·?min(?1)?·?cm(?2), which was significantly lower than normal (57.2 ± 9.2 nmol?·?min(?1)?·?cm(?2)). The HCO3(?) secretory rate was further increased by forskolin by 16.1% in normal, but not in CF tissues.Our data suggests that CF patients exhibited significantly lower base secretion by the nasal airway epithelium. It is possible that improper regulation of ASL pH in CF may negatively impact the innate host defense system.

    View details for DOI 10.1002/alr.20028

    View details for Web of Science ID 000308912300009

    View details for PubMedID 22034590

  • ACID AND BASE SECRETION IN FRESHLY EXCISED NASAL TISSUE FROM CYSTIC FIBROSIS PATIENTS WITH Delta F508 MUTATION Cho, D., Illek, B., Hwang, P. H., Fischer, H. WILEY-BLACKWELL. 2011: 241-242
  • Mechanistic Studies of Tolerance in sublingual innmunotherapy (SLIT) patients with Dermatophagoides farinae and Timothy grass allergy Reshamwala, N., Swamy, R., Berquist, S., Nguyen, T., Hoyte, E., Vissamsetti, S., Sivagnanasundaram, A., Saper, V., Hwang, P., Moss, R., Nadeau, K. ACADEMIC PRESS INC ELSEVIER SCIENCE. 2010: S65-S65
  • Determinants of outcomes of sinus surgery: A multi-institutional prospective cohort study Smith, T. L., Litvack, J. R., Hwang, P. H., Loehr, T. A., Mace, J. C., Fong, K. J., James, K. E. SAGE PUBLICATIONS LTD. 2010: 55-63

    Abstract

    1) To measure the proportion of patients with chronic rhinosinusitis (CRS) who experience clinically significant improvement after endoscopic sinus surgery (ESS) in a prospective, multi-institutional fashion. 2) To identify preoperative characteristics that predict clinically significant improvement in quality of life (QOL) after ESS.Prospective, multi-institutional cohort study.Academic tertiary care centers.A total of 302 patients with CRS from three centers were enrolled between July 2004 and December 2008 and followed for an average of 17.4 months postoperatively. Preoperative patient characteristics, CT scan, endoscopy score, and pre- and postoperative quality of life (QOL) data were collected. Univariate and multivariate analyses were performed.Patients improved an average of 15.8 percent (18.9 points) on the Rhinosinusitis Disability Index and 21.2 percent (21.2 points) on the Chronic Sinusitis Survey (both P < 0.001). Patients significantly improved on all eight Medical Outcomes Study Short Form-36 (SF-36) subscales (all P < 0.001). Among patients with poor baseline QOL, 71.7 percent of patients experienced clinically significant improvement on the RSDI and 76.1 percent on the CSS. Patients undergoing primary surgery were 2.1 times more likely to improve on the RSDI (95% confidence interval [CI], 1.2, 3.4; P = 0.006) and 1.8 times more likely to improve on the CSS (95% CI, 1.1, 3.1; P = 0.020) compared with patients undergoing revision surgery.In this prospective, multi-institutional study, most patients experienced clinically significant improvement across multiple QOL outcomes after ESS. Specific patient characteristics provided prognostic value with regard to outcomes.

    View details for DOI 10.1016/j.otohns.2009.10.009

    View details for Web of Science ID 000276574200011

    View details for PubMedID 20096224

  • Controlled steroid delivery via bioabsorbable stent: Safety and performance in a rabbit model Li, P. F., Downie, D., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2009: 591-596

    Abstract

    Middle turbinate lateralization, adhesions, and inflammation are causes of suboptimal sinus patency following surgery. A bioabsorbable drug-eluting stent has been developed to maintain sinus patency while providing controlled steroid delivery to the sinus mucosa. The aim of this study was to characterize the in vivo drug delivery efficacy and tolerance of this stent in a rabbit model.Bioabsorbable stents coated with mometasone furoate were placed bilaterally in the maxillary sinuses of 31 rabbits via dorsal maxillary sinusotomy. Animals were sacrificed between 5 days and 18 weeks postoperatively. Efficacy was assessed by measuring tissue concentrations of steroid in maxillary sinus and nasal mucosa and by measurement of plasma steroid concentrations. Tolerance was assessed by histological evaluation of the sinus mucosa at different time points.Therapeutic mucosal drug concentrations were attained in a time-dependent fashion (range 175-28,189 ng/g). Plasma drug concentrations were generally near or below the lower limit of quantification (15 pg/mL). Histopathological examination of the mucosa showed no differences in the reaction to steroid-coated stents versus nondrug-coated control stents, with inflammation, epithelial ulceration, and bony reaction ranging from none to mild at all time points. Microscopic fungal hyphae were noted in a small proportion of both treatment and control sinuses, without evidence of associated adverse tissue reaction.In a rabbit model, mometasone-coated bioabsorbable stents are able to provide local steroid delivery with negligible systemic absorption. Corticosteroid-eluting stents may prove useful following endoscopic sinus surgery in maintaining sinus patency and reducing inflammation.

    View details for DOI 10.2500/ajra.2009.23.3391

    View details for Web of Science ID 000272677900009

    View details for PubMedID 19958608

  • Bony abnormalities of the paranasal sinuses in patients with Wegener's granulomatosis Yang, C., Talbot, J. M., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2001: 121-125

    Abstract

    Wegener's granulomatosis is a systemic vasculitis that can affect any organ system, but primarily involves the upper and lower respiratory tracts and the kidneys. Chronic sinusitis is a well-known clinical feature of the disease. Mucosal abnormalities of the nose and paranasal sinuses have been well-characterized and range from granulomatous lesions to diffuse mucosal thickening. In contrast, abnormalities of the underlying bone of the paranasal sinuses in this disease have not been well-described, and reports have been limited. To characterize bony abnormalities of the nose and paranasal sinuses in patients with Wegener's granulomatosis, we performed a retrospective review of all patients with Wegener's granulomatosis who underwent a sinus CT scan at our institution between 1989 and 1999. Nine patients were identified. A total of 22 distinct bony abnormalities were identified in 5 patients. Specific bony findings included bony erosion and destruction of the septum and turbinates; erosion of the ethmoid sinuses; neo-osteogenesis of the maxillary, frontal, and sphenoid sinuses; and complete bony obliteration of the maxillary, frontal, and sphenoid sinuses. Although these findings are suggestive of Wegener's granulomatosis, they are not pathognomonic. Bony changes on sinus CT scan may provide radiologic evidence of underlying Wegener's granulomatosis when clinical suspicion is high.

    View details for Web of Science ID 000168230300009

    View details for PubMedID 11345151

  • Endoscopic septoplasty: Indications, technique, and results Hwang, P. H., McLaughlin, R. B., Lanza, D. C., Kennedy, D. W. MOSBY-ELSEVIER. 1999: 678-682

    Abstract

    Endoscopic septoplasty is an attractive alternative to traditional "headlight" approaches to septoplasty. The primary advantage of the technique is the ability to reduce morbidity and postoperative swelling in isolated septal deviations by limiting the dissection to the area of the deviation. This ability to markedly reduce the extent of subperichondrial dissection is particularly valuable in patients who have undergone prior septal cartilage resection. Other advantages include improved visualization, particularly in posterior septal deformities; improved surgical transition between septoplasty and sinus surgery; and its use as an effective teaching tool. We present our experience with endoscopic septoplasty in a series of 111 patients. Surgical indications, technique, and complications are discussed.

    View details for Web of Science ID 000080179300010

    View details for PubMedID 10229592

  • Attitudes, knowledge, and practices of otolaryngologists treating patients infected with HIV Hwang, P. H., Tami, T. A., Lee, K. C., Raven, R. B. MOSBY-YEAR BOOK INC. 1995: 733-739

    Abstract

    The AIDS epidemic has become one of the most important public health problems of this century. As the prevalence of HIV infection continues to rise, health care practitioners in all geographic regions can expect greater clinical exposure to patients infected with HIV. We conducted an anonymous survey of all practicing otolaryngologists in Ohio and California to investigate regional differences in attitudes, knowledge, and practices regarding the care of patients infected with HIV. We also examined the data with respect to year of completion of residency training to identify differences in attitudes or practices among otolaryngologists who trained in the era of AIDS (post-1982 graduates) in comparison with their predecessors (pre-1982 graduates). In comparison with Ohio otolaryngologists, California otolaryngologists reported more frequent clinical encounters with HIV-infected patients and displayed significantly better knowledge regarding the otolaryngologic aspects of HIV infection. Californians were more likely to support the right of an HIV-infected physician to maintain an unrestricted practice and would be less likely to disclose their HIV status to their patients and hospital if they were to become infected with HIV. Post-1982 graduates had more frequent encounters with HIV-infected patients than did pre-1982 graduates and demonstrated a better fund of knowledge. Although Californians were more likely than Ohioans to routinely double glove in surgery, the overall double gloving rate was low at 21%. Californians were no more likely than Ohioans to routinely use protective eyewear, water-impervious gowns, or indirect instrument-passing techniques in surgery. No differences were observed in prevalence of protective surgical precautions between pre-1982 and post-1982 graduates.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1995TK81300013

    View details for PubMedID 7501385

  • ENLARGEMENT OF THE COCHLEAR AQUEDUCT - FACT OR FICTION Jackler, R. K., Hwang, P. H. SAGE PUBLICATIONS LTD. 1993: 14-25

    Abstract

    Enlargement of the cochlear aqueduct (CA) is often mentioned in the otologic literature, usually in its purported association with sensory hearing loss, stapes gusher, and transotic cerebrospinal fluid leak. In CT scans of 100 ears, the diameter of the CA medial aperture was found to be highly variable, ranging from 0 to 11 mm, with a mean of 4.5 mm. In contrast, the otic capsule segment was very narrow in every case. It could be visualized in only 56% of cases, none of which exceeded 2 mm in diameter. Several published reports of supposed CA enlargement presented images of a dilated medial aperture that was well within the range of normal variability according to the present study. In a thorough review of the literature on radiology of the CA, we were unable to find a single published image that convincingly demonstrated enlargement of the otic capsule portion. As radiographic CA enlargement has not been convincingly reported to date, it appears to be an exceedingly rare or perhaps even nonexistent malformation. It is important to recognize than even a radiographically normal CA may be hyperpatent. It is theoretically possible for increased fluid flow to result from either deficiencies in intraluminal membrane baffles or subtle canal enlargement beneath the resolution limits of CT scanning. However, as fluid flow through a tube is regulated by its narrowest point, it is extremely improbable that stapes gusher, transotic CSF leak, and vigorous perilymphatic fistula are generated by the CA when CT scans show any portion of it to be very narrow. A substantial body of evidence points to a deficient partition between the internal auditory canal and inner ear as causative in such cases. We propose that the criteria for the diagnosis of CA enlargement on high-resolution CT scan be a diameter exceeding 2 mm throughout its course from the posterior fossa to the vestibule.

    View details for Web of Science ID A1993LP14800004

    View details for PubMedID 8336962

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