Dr. Hwang completed his undergraduate degree at Stanford University, and his MD and otolaryngology residency at the University of California, San Francisco. After completing a fellowship in rhinology at the University of Pennsylvania, Dr. Hwang served as Director of Rhinology at Oregon Health & Science University. He returned to Stanford in 2005 to lead the Division of Rhinology and Endoscopic Skull Base Surgery and currently serves as Vice Chair of Clinical Affairs for the Department of Otolaryngology-Head & Neck Surgery. Dr. Hwang has served in leadership of the American Rhinologic Society for over a decade, most recently as President of the society. Dr. Hwang also serves as Associate Editor of the International Forum of Allergy and Rhinology and Associate Editor of the World Journal of Otolaryngology. He co-edited the textbook "Rhinology: Diseases of the Nose, Sinuses, & Skull Base," which was awarded the Benjamin Franklin Award for Scientific & Technical Book of the Year. Dr. Hwang teaches on the latest advances in endoscopic sinus and skull base surgery at many national and international venues. He also trains future academic leaders in rhinology through the Stanford fellowship in rhinology and endoscopic skull base surgery. His research interests include clinical outcomes of endoscopic skull base surgery; ion transport dysregulation in rhinosinusitis; and novel topical therapies for chronic rhinosinusitis.

Clinical Focus

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

Academic Appointments

  • Professor - Med Center Line, Otolaryngology - Head & Neck Surgery Divisions
  • Professor - Med Center Line (By courtesy), Neurosurgery

Administrative Appointments

  • Vice Chair of Clinical Affairs, Department of Otolaryngology-Head & Neck Surgery (2015 - Present)
  • 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 - 2015)

Boards, Advisory Committees, Professional Organizations

  • President, American Rhinologic Society (2015 - Present)
  • President-Elect, American Rhinologic Society (2014 - 2015)
  • Associate Editor, World Journal of Otolaryngology-Head & Neck Surgery (2015 - Present)
  • 1st Vice President, American Rhinologic Society (2013 - 2014)
  • Associate Editor, International Forum of Allergy & Rhinology (2011 - Present)

Professional Education

  • Board Certification: Otolaryngology, American Board of Otolaryngology (1997)
  • 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

Clinical Trials

  • Intranasal Bevacizumab for HHT-Related Epistaxis Recruiting

    This is a randomized, controlled, double-blind, placebo-controlled trial of intranasal Avastin (bevacizumab) injection versus saline control for control of HHT-related epistaxis when used in conjunction with bipolar electrocautery.

    View full details

  • Identification and Characterization of Novel Proteins and Genes in Head and Neck Cancer Recruiting

    Through this study, we hope to learn more about the mechanisms, which may contribute to development and progression of head and neck cancer. The long-term goal of this study will be to develop new strategies and drugs for the diagnosis and treatment of head and neck cancer.

    View full details


2017-18 Courses

Stanford Advisees


All Publications

  • Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling. International forum of allergy & rhinology Nayak, J. V., Rathor, A., Grayson, J. W., Bravo, D. T., Velasquez, N., Noel, J., Beswick, D. M., Riley, K. O., Patel, Z. M., Cho, D., Dodd, R. L., Thamboo, A., Choby, G. W., Walgama, E., Harsh, G. R., Hwang, P. H., Clemons, L., Lowman, D., Richman, J. S., Woodworth, B. A. 2018


    BACKGROUND: To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing.METHODS: In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases.RESULTS: Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion.CONCLUSION: This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.

    View details for DOI 10.1002/alr.22156

    View details for PubMedID 29856526

  • Comparison of outcomes following culture-directed vs non-culture-directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis. International forum of allergy & rhinology Yan, C. H., Tangbumrungtham, N., Maul, X. A., Ma, Y., Nayak, J. V., Hwang, P. H., Patel, Z. M. 2018


    BACKGROUND: Acute exacerbations in patients with chronic rhinosinusitis (CRS) are often treated with courses of systemic antibiotics. Poor correlation between microbiologic culture results and the sinus microbiome in CRS has caused increased debate as to the relevance of culture-directed antibiotics. There is currently sparse data comparing outcomes of culture-directed antibiotics vs non-culture-directed antibiotics for treatment of CRS.METHODS: This work reports a retrospective review. A total of 946 CRS patients treated with antibiotics were examined; 122 CRS patients with acute exacerbations were treated with culture-directed (n = 61) vs empiric (n = 61) antibiotics. Lund-Kennedy (LK) and 22-item Sino-Nasal Outcome Test (SNOT-22) scores were compared pretreatment and posttreatment, with short-term (<1 month) and long-term (1-6 months) follow-up. Patient demographics, comorbidities, and prior surgical history were collected.RESULTS: Both groups had similar pretreatment SNOT-22 scores (p = 0.25) while the culture group had higher baseline LK endoscopy scores (p < 0.01). All data were adjusted for pertinent comorbidities, surgical history, co-therapeutics, and baseline scores. There was no difference in improvement in culture-directed and empirically treated groups in the short-term (p = 0.77) and long-term (p = 0.58) for minimal clinically important difference (MCID) of SNOT-22 and no difference in the short-term for LK scores (p = 0.11), but there was significantly more improvement in long-term LK scores in the culture-directed group (p = 0.01).CONCLUSION: Culture-directed therapy improves long-term endoscopy scores but does not yield an advantage in improving short-term endoscopy scores, nor in improving short-term and long-term quality of life scores in CRS patients. A prospective study is necessary to examine the relevance of routine microbiologic cultures in CRS patients.

    View details for DOI 10.1002/alr.22147

    View details for PubMedID 29782068

  • Risk Stratification for Postoperative Venous Thromboembolism after Endoscopic Sinus Surgery OTOLARYNGOLOGY-HEAD AND NECK SURGERY Beswick, D. M., Vaezeafshar, R., Ma, Y., Hwang, P. H., Nayak, J. V., Patel, Z. M. 2018; 158 (4): 767?73


    Objectives Venous thromboembolism (VTE) contributes to significant patient morbidity, yet the incidence of VTE following endoscopic sinus surgery (ESS) is unknown. Quality improvement criteria are prompting increased standardization of perioperative VTE prophylaxis. Risk stratification for VTE may better define best practice measures to balance limiting VTE development with avoiding unnecessary chemoprophylaxis. Study Design Retrospective cohort study. Setting Tertiary institution. Subjects and Methods Adult patients who underwent ESS without perioperative chemoprophylaxis from 2008 to 2016 were evaluated. Identification of VTE was performed via screening diagnosis and procedure codes and clinical records, with subsequent confirmation of true-positive VTE. Data for individual Caprini scores were abstracted from electronic medical records. The primary outcome was development of VTE within 30 days following ESS relative to the Caprini score. Results A total of 2369 ESS cases were evaluated. While initial screening identified multiple potential VTE events, in-depth medical record review confirmed only 4 true VTE (0.17%). The VTE rate among cases with a Caprini score of <8 (0.09%, 2/2278) was significantly less ( P = .008) than the rate with a score of ?8 (2.2%, 2/91). Beyond overall score, specific risk factors associated with development of postoperative VTE included stroke, central venous access, sepsis, and inpatient status (all P < .025), while prior VTE and hypercoagulability were not associated with postoperative VTE (all P > .5). Conclusions In the absence of perioperative chemoprophylaxis, postoperative VTE following ESS is extremely rare, particularly for patients carrying low-to-moderate Caprini scores. Risk stratification based on these data can assist in the design of VTE prophylaxis guidelines for ESS patients.

    View details for DOI 10.1177/0194599818755340

    View details for Web of Science ID 000429905500026

    View details for PubMedID 29460675

  • Computed tomography analysis of frontal cell prevalence according to the International Frontal Sinus Anatomy Classification. International forum of allergy & rhinology Choby, G., Thamboo, A., Won, T., Kim, J., Shih, L. C., Hwang, P. H. 2018


    BACKGROUND: The International Frontal Sinus Anatomy Classification (IFAC) is an international consensus document published in 2016 to standardize the nomenclature of cells in the region of the frontal recess and frontal sinus. The IFAC was designed to be surgically relevant and anatomically precise. The current study was undertaken to assess the prevalence of the frontal cell variants as defined by the IFAC, as well as to determine the interrater reliability of the IFAC.METHODS: Three independent reviewers examined triplanar nondiseased maxillofacial computed tomography (CT) scans to assess the anatomy of the frontal recess according to the IFAC system. The prevalence of each cell type was assessed and interrater reliability was measured using an intraclass correlation coefficient (ICC).RESULTS: One hundred CT scans (200 sides) were examined. Of the 200 sides, 96.5% contained an agger nasi cell (ICC, 0.82; 95% confidence interval [CI], 0.77-0.86), 30.0% contained a supra agger cell (ICC, 0.89; 95% CI, 0.86-0.92), 20.0% contained a supra agger frontal cell (ICC 0.80; 95% CI 0.74-0.84), 72.0% contained a supra bulla cell (ICC, 0.81; 95% CI, 0.76-0.85), 5.5% contained a supra bulla frontal cell (ICC, 0.71; 95% CI, 0.63-0.77), 28.5% contained a supraorbital ethmoid cell (ICC, 0.78; 95% CI, 0.72-0.83), and 30.0% contained a frontal septal cell (ICC, 0.80; 95% CI, 0.74-0.84). The ICC was good to excellent for identification of all frontal cell types.CONCLUSIONS: This study describes the normative distribution of frontal recess cells in a nondiseased population according to IFAC and demonstrates favorable interrater reliability of the classification system.

    View details for DOI 10.1002/alr.22105

    View details for PubMedID 29457874

  • Evolution of the endoscopic modified Lothrop procedure: A systematic review and meta-analysis. The Laryngoscope Shih, L., Patel, V. S., Choby, G. W., Nakayama, T., Hwang, P. H. 2018; 128 (2): 317?26


    OBJECTIVE: Since first described in the 1990s, the endoscopic modified Lothrop procedure (EMLP) has been the subject of a growing body of literature. We performed a review to compare indications and outcomes of EMLP in an early cohort of publications (1990-2008) versus a contemporary cohort (2009-2016) and compare outcomes associated with follow-up ?2 years versus <2 years.DATA SOURCES: PubMed, SCOPUS and Cochrane databases.REVIEW METHODS: An English-language search of the PubMed and Ovid databases was conducted to identify publications from 1990 to 2016 reporting clinical outcomes of EMLP. Meta-analysis was performed using Statistical Analysis System 9.4.RESULTS: A total of 1,205 patients were abstracted from 29 articles with a mean follow-up of 29.1 ± 10.3 months. The overall rate of significant or complete symptom improvement was 86.5% (95% confidence interval [CI]: 84.2%-88.7%). The overall patency rate was 90.7% (95% CI: 89.1%-92.3%), with a revision rate of 12.6% (95% CI: 10.6%-14.3%). Compared to the early cohort, patients in the contemporary cohort underwent EMLP more often for tumors (P < .001), had higher rates of complete or significant symptom improvement (90.0% vs. 82.6 %, P < .001); and trended toward greater patency rates (92.1% vs. 88.6%, P = .052). Compared to the short-term follow-up cohort, the long-term cohort showed no differences in symptom improvement or patency, but the revision rate was higher (14.5% vs. 9.2%, P = .016).CONCLUSIONS: In the last decade, EMLP has been performed more frequently for tumors. Recent studies have demonstrated improved symptom outcomes and a trend toward improved patency rates. The revision rate increased significantly when follow-up exceeded 2 years. Laryngoscope, 128:317-326, 2018.

    View details for DOI 10.1002/lary.26794

    View details for PubMedID 28921539

  • International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Wise, S. K., Lin, S. Y., Toskala, E., Orlandi, R. R., Akdis, C. A., Alt, J. A., Azar, A., Baroody, F. M., Bachert, C., Canonica, G., Chacko, T., Cingi, C., Ciprandi, G., Corey, J., Cox, L. S., Creticos, P., Custovic, A., Damask, C., DeConde, A., DelGaudio, J. M., Ebert, C. S., Eloy, J., Flanagan, C. E., Fokkens, W. J., Franzese, C., Gosepath, J., Halderman, A., Hamilton, R. G., Hoffman, H., Hohlfeld, J. M., Houser, S. M., Hwang, P. H., Incorvaia, C., Jarvis, D., Khalid, A. N., Kilpelaeinen, M., Kingdom, T. T., Krouse, H., Larenas-Linnemann, D., Laury, A. M., Lee, S. E., Levy, J. M., Luong, A. U., Marple, B. F., McCoul, E. D., McMains, K., Melen, E., Mims, J. W., Moscato, G., Mullol, J., Nelson, H. S., Patadia, M., Pawankar, R., Pfaar, O., Platt, M. P., Reisacher, W., Rondon, C., Rudmik, L., Ryan, M., Sastre, J., Schlosser, R. J., Settipane, R. A., Sharma, H. P., Sheikh, A., Smith, T. L., Tantilipikorn, P., Tversky, J. R., Veling, M. C., Wang, D., Westman, M., Wickman, M., Zacharek, M., Andiappan, A., Badorrek, P., Brook, C. D., Campo, P., Chaaban, M. R., Charles-Jones, A., Cheng, E., Chhabra, N., Cox, D., Daraei, P., Drucker, A. M., Fruth, K., Guo, C., Kopp, M., Loftus, P. A., Lopez-Chacon, M., Marino, M. J., Mattos, J., Muluk, N., Ng, C., Nwaru, B. I., Pala, G., Paulin, J., Pfisterer, M., Rosko, A. J., Russo, C., Schuman, T., Segboer, C., Silvestri, M., Smith, K. A., Soyka, M. B., Lujan, J., Thomas, A. J., Viinanen, A., Willson, T. J. 2018; 8 (2): 108?352


    Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

    View details for DOI 10.1002/alr.22073

    View details for Web of Science ID 000424909200003

    View details for PubMedID 29438602

  • Early experience with a patient-specific virtual surgical simulation for rehearsal of endoscopic skull-base surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Won, T., Hwang, P., Lim, J., Cho, S., Paek, S., Losorelli, S., Vaisbuch, Y., Chan, S., Salisbury, K., Blevins, N. H. 2018; 8 (1): 54?63


    With the help of contemporary computer technology it is possible to create a virtual surgical environment (VSE) for training. This article describes a patient-specific virtual rhinologic surgical simulation platform that supports rehearsal of endoscopic skull-base surgery. We also share our early experience with select cases.A rhinologic VSE was developed, featuring a highly efficient direct 3-dimensional (3D) volume renderer with simultaneous stereoscopic feedback during surgical manipulation of the virtual anatomy, as well as high-fidelity haptic feedback. We conducted a retrospective analysis on 10 patients who underwent various forms of sinus and ventral skull-base surgery to assess the ability of the rhinologic VSE to replicate actual intraoperative findings.In all 10 cases, the simulation experience was realistic enough to perform dissections in a similar manner as in the actual surgery. Excellent correlation was found in terms of surgical exposure, anatomical features, and the locations of pathology.The current rhinologic VSE shows sufficient realism to allow patient-specific surgical rehearsal of the sinus and ventral skull base. Further validation studies are needed to assess the benefits of performing patient-specific rehearsal.

    View details for DOI 10.1002/alr.22037

    View details for Web of Science ID 000419640200009

    View details for PubMedID 29105367

  • Outcomes After Endoscopic Endonasal Resection of Craniopharyngiomas in the Pediatric Population WORLD NEUROSURGERY Patel, V. S., Thamboo, A., Quon, J., Nayak, J. V., Hwang, P. H., Edwards, M., Patel, Z. M. 2017; 108: 6?14
  • Comparison of surgical outcomes between patients with unilateral and bilateral chronic rhinosinusitis Beswick, D. M., Mace, J. C., Chowdhury, N. I., Alt, J. A., Hwang, P. H., DeConde, A. S., Smith, T. L. WILEY. 2017: 1162?69

    View details for DOI 10.1002/alr.22020

    View details for Web of Science ID 000417284900009

  • Evidence for altered levels of IgD in the nasal airway mucosa of patients with chronic rhinosinusitis JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY Min, J., Nayak, J. V., Hulse, K. E., Stevens, W. W., Raju, P. A., Huang, J. H., Suh, L. A., Van Roey, G. A., Norton, J. E., Carter, R. G., Price, C. E., Weibman, A. R., Rashan, A. R., Ghosn, E. E., Patel, Z. M., Homma, T., Conley, D. B., Welch, K. C., Shintani-Smith, S., Peters, A. T., Grammer, L. C., Harris, K. E., Kato, A., Hwang, P. H., Kern, R. C., Herzenberg, L. A., Schleimer, R. P., Tan, B. K. 2017; 140 (6): 1562-+


    IgD is an enigmatic antibody isotype best known when coexpressed with IgM on naive B cells. However, increased soluble IgD (sIgD) levels and increased IgD+IgM- B-cell populations have been described in the human upper respiratory mucosa.We assessed whether levels of sIgD and IgD+ B cell counts are altered in nasal tissue from patients with chronic rhinosinusitis (CRS). We further characterized IgD+ B-cell populations and explored clinical and local inflammatory factors associated with tissue sIgD levels.sIgD levels were measured by means of ELISA in nasal tissues, nasal lavage fluid, sera, and supernatants of dissociated nasal tissues. IgD+ cells were identified by using immunofluorescence and flow cytometry. Inflammatory mediator levels in tissues were assessed by using real-time PCR and multiplex immunoassays. Bacterial cultures from the middle meatus were performed. Underlying medical history and medicine use were obtained from medical records.sIgD levels and numbers of IgD+ cells were significantly increased in uncinate tissue (UT) of patients with chronic rhinosinusitis without nasal polyps (CRSsNP) compared with that of control subjects (4-fold, P < .05). IgD+ cells were densely scattered in the periglandular regions of UT from patients with CRSsNP. We also found that IgD+CD19+CD38bright plasmablast numbers were significantly increased in tissues from patients with CRSsNP compared with control tissues (P < .05). Among numerous factors tested, IL-2 levels were increased in UT from patients with CRSsNP and were positively correlated with tissue IgD levels. Additionally, supernatants of IL-2-stimulated dissociated tissue from patients with CRSsNP had significantly increased sIgD levels compared with those in IL-2-stimulated dissociated control tissue ex vivo (P < .05). Tissue from patients with CRS with preoperative antibiotic use or those with pathogenic bacteria showed higher IgD levels compared with tissue from patients without these variables (P < .05).sIgD levels and IgD+CD19+CD38bright plasmablast counts were increased in nasal tissue of patients with CRSsNP. IgD levels were associated with increased IL-2 levels and the presence of pathogenic bacteria. These findings suggest that IgD might contribute to enhancement mucosal immunity or inflammation or respond to bacterial infections in patients with CRS, especially CRSsNP.

    View details for DOI 10.1016/j.jaci.2017.05.032

    View details for Web of Science ID 000417206000010

    View details for PubMedID 28625807

    View details for PubMedCentralID PMC5723216

  • Cryosurgical posterior nasal tissue ablation for the treatment of rhinitis Hwang, P. H., Lin, B., Weiss, R., Atkins, J., Johnson, J. WILEY. 2017: 952?56


    Endoscopic posterior nasal nerve (PNN) resection has been described as an efficacious surgical treatment of allergic and nonallergic rhinitis, but the requirement for surgery under general anesthesia has limited its acceptance. We report the first series of patients treated for chronic rhinitis using a novel device designed for office-based cryosurgical ablation of the PNN.Twenty-seven patients with chronic rhinorrhea and/or nasal congestion for >3 months were recruited (allergic or nonallergic rhinitis), with minimum rhinorrhea and/or congestion subscores of 2 as part of the Total Nasal Symptom Score [TNSS]). Under local anesthesia, the cryotherapy device was applied endoscopically to the posterior middle meatus and was used to freeze the PNN region bilaterally. Patients were followed up after 7, 30, 90, 180, and 365 days to assess TNSS.The procedure was successfully completed in 100% of patients, with no complications; 74% reported no or mild discomfort by the first postprocedure day. TNSS was reduced significantly at 30 days (mean ± standard deviation: 6.2 ± 0.5 at baseline, 2.6 ± 0.3 at 30 days, n = 27, p < 0.001), with continued reduction at 90 (2.7 ± 0.4, n = 24, p < 0.001), 180 (2.3 ± 0.5, n = 21, p < 0.001), and 365 days (1.9 ± 0.3, n = 15, p < 0.001). Both rhinorrhea and congestion subscores decreased significantly at 30, 90, 180, and 365 days compared to baseline (p < 0.001). Allergic and nonallergic subcohorts both appeared to benefit from treatment.Office-based cryotherapy of the PNN region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days.

    View details for DOI 10.1002/alr.21991

    View details for Web of Science ID 000412135100004

    View details for PubMedID 28799727

    View details for PubMedCentralID PMC5656830

  • Selective expansion of human regulatory T cells in nasal polyps, and not adjacent tissue microenvironments, in individual patients exposed to steroids. Clinical immunology Edward, J. A., Sanyal, M., Le, W., Soudry, E., Ramakrishnan, V. R., Bravo, D. T., Nguyen, A. L., Zarabanda, D., Kingdom, T. T., Hwang, P. H., Garrison Fathman, C., Nayak, J. V. 2017; 179: 66-76


    Severe forms of chronic rhinosinusitis (CRS), a common upper airway inflammatory disorder, are associated with nasal polyps (NPs). NP disease is ameliorated by glucocorticoid (GC) treatment, whose cellular effects are poorly understood. We therefore assessed the influence of GC therapy on NPs in CRS patients, focusing on regulatory T (Treg) cells. Treg cell populations were analyzed by flow cytometry in NPs and control tissues from GC-treated CRS patients and controls. After GC exposure, selective expansion of Treg cells was seen within NPs, and not blood or adjacent ethmoid tissues. To confirm direct GC effects, NPs from the same patients were biopsied prior to, and following, 1week of oral GC exposure. Direct expansion of Tregs into the same NP bed was detected in 4/4 CRS patients following GC exposure. Treg cell spikes into NPs were secondary to cellular recruitment given limited Ki67 expression within these regulatory cells. Chemokine gene expression profiling identified several chemokines, notably CCL4, induced within NPs upon GC treatment. Neutralization of chemokine receptor/ligand interactions using CCR4 small molecule antagonists reduced Treg migration towards GC-treated NPs in an ex vivo migration assay. Our findings suggest that the common use of GCs in the treatment of NP disease leads to recruitment of Treg cells from peripheral sites into NP tissues, which may be critical to the anti-inflammatory effect of GCs. Mechanistically Treg expansion appears to be conferred, in part, by chemokine receptor/ligand interactions induced following corticosteroid therapy.

    View details for DOI 10.1016/j.clim.2017.02.002

    View details for PubMedID 28279811

  • Determinants and outcomes of upfront surgery versus medical therapy for chronic rhinosinusitis in cystic fibrosis. International forum of allergy & rhinology Ayoub, N., Thamboo, A., Habib, A., Nayak, J. V., Hwang, P. H. 2017


    The indications for surgical management of chronic rhinosinusitis (CRS) in patients with cystic fibrosis (CF) are poorly defined. In this study we compare outcomes of medical versus surgical treatment and examine trends associated with the transition from medical to surgical therapy in CF patients.One hundred thirty-six patients with CF referred to a tertiary rhinology practice were retrospectively divided into 3 cohorts: Medical, Upfront Surgery, or Crossover, if they converted from medical to surgical management. The 22-item Sino-Nasal Outcome Test (SNOT-22) and pulmonary function test (PFT) data were assessed up to 48 months.Compared to patients initially managed medically (n = 90), those who pursued upfront surgery (n = 46) had a greater incidence of nasal polyposis (p = 0.0011), prior sinus surgery (p = 0.0025), lower percent-predicted forced expiratory volume in 1 second (%FEV1 ) (p = 0.0063), and higher Lund-Mackay (p = 0.0025) and SNOT-22 (p = 0.0229) scores. Within the medical group, 35.5% converted to surgery after a mean of 14.3 months. Crossover (n = 32) was associated with a 6.1-point increase in SNOT-22 and a 4.5% deterioration in %FEV1 . Despite worsened symptom severity, the Crossover cohort ultimately achieved similar postoperative SNOT-22 scores (p = 0.831) and %FEV1 (p = 0.114) as those who underwent upfront surgery. Although the Medical cohort had the lowest baseline SNOT-22 scores (p < 0.001), surgery at any time normalized scores to the same baseline level (p = 0.652). Neither medical therapy nor surgery improved PFTs.Surgery effectively reduces CRS-related symptoms in CF patients but may not improve pulmonary function. In patients who first pursue medical therapy, symptomatic decline may prompt eventual conversion to surgery. Patients who delay surgery may achieve similar outcomes as those who pursue surgery upfront.

    View details for DOI 10.1002/alr.21912

    View details for PubMedID 28218486

  • Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis. International forum of allergy & rhinology Patel, Z. M., Thamboo, A., Rudmik, L., Nayak, J. V., Smith, T. L., Hwang, P. H. 2017; 7 (2): 119-127


    The currently accepted treatment paradigm of treating chronic rhinosinusitis (CRS) first with appropriate medical therapy (AMT) and then with surgery if patients are refractory to AMT, has been criticized for lack of evidence. The objective of this study was to reassess the literature and establish the highest level of evidence possible regarding further management of CRS patients refractory to AMT.This study was a systematic review (SR) with meta-analysis (MA). Adult CRS patients who received AMT and then underwent either medical or surgical therapy in moderate to high level prospective studies were included. Outcomes assessed were disease-specific quality of life (QOL), nasal endoscopy, health-state utility, missed work days, change in cardinal symptoms of CRS, economic impact, and adverse events.A total of 970 manuscripts were identified; 6 studies were ultimately included in the SR with 5 included in the MA. Compared to continued medical therapy, endoscopic sinus surgery (ESS) significantly improved patient-based QOL scores (p < 0.00001) and nasal endoscopy scores (p < 0.00001). Difference in missed work days depended heavily on patient choice of intervention. Unpooled analysis showed improvements in olfaction, health utility scores, and cost-effectiveness.On meta-analysis, for CRS patients refractory to AMT, ESS significantly improves objective endoscopic scoring outcomes vs continued medical therapy alone. In patients with refractory CRS who have significant reductions in baseline QOL, ESS results in significant improvements. Continued medical therapy appears to maintain outcomes in patients with less severe baseline QOL. Unpooled analysis demonstrates improvement in health utility, olfaction, and cost-effectiveness following ESS compared to continued medical therapy alone, in medically refractory CRS.

    View details for DOI 10.1002/alr.21872

    View details for PubMedID 27863163

  • Aspirin-Exacerbated Respiratory Disease OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Walgama, E. S., Hwang, P. H. 2017; 50 (1): 83-?


    Aspirin-exacerbated respiratory disease (AERD) is characterized by the triad of asthma, sinonasal polyposis, and aspirin intolerance. The hallmark of the disease is baseline overproduction of cysteinyl leukotrienes via the 5-lipoxygenase pathway, exacerbated by ingestion of aspirin. Patients with AERD have high rates of recidivistic polyposis following sinus surgery, although the improvement in quality of life following surgery is similar to aspirin-tolerant patients. The diagnosis is secured by a positive aspirin provocation test, usually administered by a medical allergist. Aspirin therapy is a unique treatment consideration for patients with AERD.

    View details for DOI 10.1016/j.otc.2016.08.007

    View details for Web of Science ID 000390983700008

    View details for PubMedID 27888917

  • Comparing Surgeon Outcomes in Endoscopic Sinus Surgery for Chronic Rhinosinusitis LARYNGOSCOPE Smith, T. L., Mace, J. C., Rudmik, L., Schlosser, R. J., Hwang, P. H., Alt, J. A., Soler, Z. M. 2017; 127 (1): 14-21

    View details for DOI 10.1002/lary.26095

    View details for Web of Science ID 000394951400017

  • Nose blowing after endoscopic sinus surgery does not adversely affect outcomes. The Laryngoscope Ayoub, N., Chitsuthipakorn, W., Nayak, J. V., Patel, Z. M., Hwang, P. H. 2017


    Patients frequently are advised to abstain from nose blowing following endoscopic sinus surgery (ESS), despite a lack of evidence supporting this recommendation. This randomized study assessed whether nose blowing in the first postoperative week affects subjective and objective clinical outcomes.Forty patients undergoing ESS were randomized into an interventional arm in which patients blew their nose at least twice daily for the first 7 postoperative days, or a control arm in which patients refrained from nose blowing. All patients were allowed to blow their nose after 7 days. The frequency and degree of epistaxis was documented by daily diary and visual analog scale (VAS). At 1 and 4 weeks postoperatively, Nasal Obstruction Symptom Evaluation (NOSE) and Sino-Nasal Outcome Test-22 (SNOT-22) were collected, and endoscopies were recorded for blinded Lund-Kennedy scale scoring.There were no differences between the two groups in terms of frequency and duration of bleeding events, VAS epistaxis scores, SNOT-22 scores, and NOSE scores at every postoperative timepoint. Lund-Kennedy scores also were similar at the 1-week (P = 0.0762) and 4-week (P = 0.2340) postoperative visits, but the nose-blowing group had improved nasal discharge subscores at the first (P = 0.0075) and second (P = 0.0298) postoperative visits.Nose blowing after ESS does not appear to measurably improve symptoms of nasal congestion or general sinonasal quality of life, nor does it seem to adversely affect the frequency or severity of postoperative epistaxis during the first postoperative week. Judicious nose blowing may be permissible immediately after uncomplicated ESS.1b. Laryngoscope, 2017.

    View details for DOI 10.1002/lary.26907

    View details for PubMedID 29068050

  • Equivalence in outcomes between Draf 2B vs Draf 3 frontal sinusotomy for refractory chronic frontal rhinosinusitis. International forum of allergy & rhinology Patel, V. S., Choby, G., Shih, L. C., Patel, Z. M., Nayak, J. V., Hwang, P. H. 2017


    Endoscopic Draf 2B and Draf 3 frontal sinusotomies are frequently performed for chronic refractory frontal rhinosinusitis. The purpose of this study was to compare outcomes between Draf 2B and Draf 3 procedures.A retrospective cohort study was conducted comparing patients undergoing bilateral Draf 2B vs Draf 3 procedures from 2000 to 2016. Patients with neoplasia, dysplasia, mucocele, cystic fibrosis, or ciliary dyskinesia were excluded. Preoperative disease parameters included number of prior surgeries, presence of polyps, preoperative 22-item Sino-Nasal Outcome Test (SNOT-22) score, frontal Lund-Mackay score, anterior-posterior diameter of the frontal ostium, and Global Osteitis Scoring Scale (GOSS). Postoperative outcomes included SNOT-22 score, neo-ostium patency, surgical revision rates, and complications.A total of 21 patients with bilateral Draf 2B and 17 patients with Draf 3 surgeries were compared. Mean follow-up time was 15.6 months. No significant differences were seen between groups for any preoperative disease parameter. Both cohorts showed statistically significant (p = 0.0001 [Draf 2B]; p = 0.0001 [Draf 3]) and clinically meaningful (? = 24.1; ? = 24.9) improvements in SNOT-22 at last follow-up vs preoperatively. The Draf 2B group had greater improvement in SNOT-22 score than the Draf 3 group at 1 to 3 months (p = 0.003), but the magnitude of improvement equalized at 5 to 9 months (p = 0.66) and last follow-up (p = 0.90). No significant differences were noted between groups regarding patency, revision rates, or complications.Both Draf 2B and Draf 3 procedures offer durable symptomatic improvement for patients with refractory frontal CRS. The Draf 2B is associated with earlier postoperative symptom improvement and overall shows comparable long-term outcomes to the Draf 3 sinusotomy.

    View details for DOI 10.1002/alr.22032

    View details for PubMedID 29131540

  • The prevalence of Eustachian tube dysfunction symptoms in patients with chronic rhinosinusitis. International forum of allergy & rhinology Tangbumrungtham, N., Patel, V. S., Thamboo, A., Patel, Z. M., Nayak, J. V., Ma, Y., Choby, G., Hwang, P. H. 2017


    While Eustachian tube dysfunction (ETD) is a known comorbidity of chronic rhinosinusitis (CRS), the prevalence of ETD symptoms in the CRS population is poorly understood. We sought to determine the cross-sectional prevalence of ETD in patients with CRS using the validated Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and to correlate ETDQ-7 scores with 22-item Sino-Nasal Outcome Test (SNOT-22) scores, endoscopy scores, and computed tomography (CT) scores.A total of 101 patients with confirmed CRS completed the ETDQ-7 and SNOT-22 at their initial visit to our rhinology clinic. Lund-Mackay CT and Lund-Kennedy endoscopy scores were also obtained. Spearman's correlation coefficient (?) was calculated.Among the 101 patients, 49 patients (48.5%) had an ETDQ-7 score of ?14.5, signifying clinically significant ETD. The mean ± standard deviation (SD) ETDQ-7 score of the entire cohort was 17.8 ± 10.1. There was a moderately strong correlation between ETDQ-7 and the SNOT-22 ear subdomain (? = 0.691, p < 0.001). The correlation coefficient between ETDQ-7 and total SNOT-22 scores was ? = 0.491 (p < 0.001), indicating moderate correlation. ETDQ-7 scores were poorly correlated to objective measures of sinonasal disease, including Lund-Mackay CT score (? = -0.055, p = 0.594) and Lund-Kennedy endoscopy score (? = -0.099, p = 0.334).Symptoms of ETD are highly prevalent among patients with CRS as documented by patient-reported outcome measures. The correlation between ETDQ-7 scores and SNOT-22 ear subdomain scores is moderately strong, while the correlation between ETDQ-7 scores and SNOT-22 scores is moderate. ETD severity does not correlate with CT score or nasal endoscopy score.

    View details for DOI 10.1002/alr.22056

    View details for PubMedID 29227048

  • Practice patterns in pediatric chronic rhinosinusitis: A survey of the American Rhinologic Society AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Beswick, D. M., Ramadan, H., Baroody, F. M., Hwang, P. H. 2016; 30 (6): 418-423


    The management of pediatric chronic rhinosinusitis (PCRS) is evolving.To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS.A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership.The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD.Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.

    View details for DOI 10.2500/ajra.2016.30.4373

    View details for Web of Science ID 000390857000015

    View details for PubMedID 28124653

  • Design and rationale of a prospective, multi-institutional registry for patients with sinonasal malignancy. Laryngoscope Beswick, D. M., Holsinger, F. C., Kaplan, M. J., Fischbein, N. J., Hara, W., Colevas, A. D., Le, Q., Berry, G. J., Hwang, P. H. 2016; 126 (9): 1977-1980


    Assessment of patients with sinonasal malignancy is challenging due to the low disease incidence and diverse histopathology. The current literature is composed mainly of retrospective studies with heterogeneous cohorts, and the rarity of cases limits our understanding of disease characteristics and treatment outcomes. We describe the development of a prospective, multi-institutional registry that utilizes cloud-based computing to evaluate treatment outcomes in patients with sinonasal cancer.A web-based, secure database was built to prospectively capture longitudinal outcomes and quality-of-life (QoL) data in patients diagnosed with sinonasal malignancy. Demographics, tumor staging, and treatment outcomes data are being collected. The Sinonasal Outcome Test-22 and University of Washington Quality of Life Questionnaire are administered at presentation and at recurring intervals. To date, seven institutions are participating nationally.This prospective, multi-institutional registry will provide novel oncological and QoL outcomes on patients with sinonasal malignancy to inform management decisions and disease prognostication. The application of cloud-based computing facilitates secure multi-institutional collaboration and may serve as a model for future registry development for the study of rare diseases in otolaryngology.2C. Laryngoscope, 2016.

    View details for DOI 10.1002/lary.25996

    View details for PubMedID 27283472

  • The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery (EFSS) INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Wormald, P., Hoseman, W., Callejas, C., Weber, R. K., Kennedy, D. W., Citardi, M. J., Senior, B. A., Smith, T. L., Hwang, P. H., Orlandi, R. R., Kaschke, O., Siow, J. K., Szczygielski, K., Goessler, U., Khan, M., Bernal-Sprekelsen, M., Kuehnel, T., Psaltis, A. 2016; 6 (7): 677-696


    The frontal recess and frontal sinus anatomy can vary from simple to complex. The variations in the anatomy of the frontal recess and frontal sinus are considerable but almost all variations can be classified if the various cell patterns are analyzed. This consensus document was developed to improve the ability of the surgeon to understand these possible variations, plan the surgery, and communicate these complexities when teaching or reporting outcomes. Once the surgeon understands the anatomical pattern of the frontal sinus and recess cells, the extent of surgery can be planned. This document presents a classification of the extent of surgery based on the anatomical classification.

    View details for DOI 10.1002/alr.21738

    View details for Web of Science ID 000379907400002

    View details for PubMedID 26991922

  • Comparing surgeon outcomes in endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope Smith, T. L., Mace, J. C., Rudmik, L., Schlosser, R. J., Hwang, P. H., Alt, J. A., Soler, Z. M. 2016


    The objective of this investigation was to evaluate endoscopic sinus surgery (ESS) outcomes for chronic rhinosinusitis (CRS) between medical centers to determine if differences in quality-of-life outcomes were detectable. In addition, we sought to identify significant, independent cofactors toward the development of an ESS-specific risk-adjustment model so that ESS outcomes may be appropriately compared between institutions and healthcare providers.Prospective, multicenter, observational cohort.Study participants electing ESS for CRS were enrolled and randomly selected in equal numbers from three academic clinical practices in North America between April 2011 and May 2015. The magnitude of average 6-month postoperative improvement in patient-related outcome measures (PROMs) was compared between enrollment sites using multivariate linear regression modeling.A total of 228 participants met inclusion criteria and were included for final analyses (n = 76 per site). The prevalence of septal deviation/septoplasty and oral corticosteroid-dependent conditions was significantly different between enrollment sites (P ? 0.004). Each enrollment site generated significant within-subject improvement across all PROMs after ESS (P < 0.001); however, average unadjusted magnitudes of improvement were significantly different between sites for the primary outcome measure. After controlling for baseline PROMs, septal deviation, steroid-dependent conditions, and medication use variables, enrollment site was no longer associated with significant outcome differences (P = 0.535).Comparison of surgeon outcomes of ESS is feasible and must take into account a number of baseline patient characteristics. Further studies will be critical toward developing an ESS-specific risk-adjustment model and enabling a robust comparison of surgeon outcomes.2c. Laryngoscope, 127:14-21, 2017.

    View details for DOI 10.1002/lary.26095

    View details for PubMedID 27298069

  • Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations RHINOLOGY Lal, D., Jategaonkar, A. A., Borish, L., Chambliss, L. R., Gnagi, S. H., Hwang, P. H., Rank, M. A., Stankiewicf, J. A., Lund, V. J. 2016; 54 (2): 99-104


    Management of rhinosinusitis during pregnancy requires special considerations.1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations.The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea.Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations.The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.

    View details for DOI 10.4193/Rhino15.228

    View details for Web of Science ID 000378015400002

    View details for PubMedID 26800862

  • Safety analysis of long-term budesonide nasal irrigations in patients with chronic rhinosinusitis post endoscopic sinus surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Soudry, E., Wang, J., Vaezeafshar, R., Katznelson, L., Hwang, P. H. 2016; 6 (6): 568-572


    Although the safety of topical nasal steroids is well established for nasal spray forms, data regarding the safety of steroid irrigations is limited. We studied the effect of long-term budesonide nasal irrigations (>6 months) on hypothalamic-pituitary-adrenal axis (HPAA) function and intraocular pressure (IOP) in patients post-endoscopic sinus surgery.This was retrospective case series. Adrenal function was assessed by using the high-dose cosyntropin stimulation test.A total of 48 patients were assessed, with a mean duration of budesonide irrigations of 22 months. Stimulated cortisol levels were abnormally low in 11 patients (23%). None reported to have symptoms of adrenal suppression. Three of 4 patients who repeated the study being off budesonide for at least 1 month returned to near normal levels. Logistic regression analysis revealed that concomitant use of both nasal steroid sprays and pulmonary steroid inhalers was significantly associated with HPAA suppression (p = 0.024). Patients with low stimulated cortisol levels were able to continue budesonide irrigations under the supervision of an endocrinologist without frank clinical manifestations of adrenal insufficiency. IOP was within normal limits in all patients.Long-term use of budesonide nasal irrigations is generally safe, but asymptomatic HPAA suppression may occur in selected patients. Concomitant use of both nasal steroid sprays and pulmonary steroid inhalers while using daily budesonide nasal irrigations is associated with an increased risk. Rhinologists should be alerted to the potential risks of long-term use of budesonide nasal irrigations, and monitoring for HPAA suppression may be warranted in patients receiving long-term budesonide irrigation therapy.

    View details for DOI 10.1002/alr.21724

    View details for Web of Science ID 000379700700003

    View details for PubMedID 26879335

  • Outcomes of chronic frontal sinusitis treated with ethmoidectomy: a prospective study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Abuzeid, W. M., Mace, J. C., Costa, M. L., Rudmik, L., Soler, Z. M., Kim, G. S., Smith, T. L., Hwang, P. H. 2016; 6 (6): 597-604


    In medically refractory chronic frontal sinusitis, ethmoidectomy without instrumentation of the frontal ostium may resolve frontal disease. Our aim was to determine the efficacy of ethmoidectomy alone for the treatment of chronic frontal sinusitis.Adults with chronic rhinosinusitis prospectively enrolled in a multicenter study who demonstrated frontal sinusitis on computed tomography were divided into 2 groups: (1) endoscopic sinus surgery (ESS) incorporating ethmoidectomy, but excluding frontal sinusotomy; and (2) ESS incorporating frontal sinusotomy. The primary outcome was improvement in 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Secondary outcomes included endoscopic scores and use of corticosteroids and antibiotics.A total of 196 cases undergoing frontal sinusotomy and 30 cases treated with ethmoidectomy without frontal sinusotomy were analyzed and were comparable demographically. The prevalence of nasal polyps, previous ESS, asthma, and aspirin intolerance was more common in the frontal sinusotomy group (p < 0.050). Preoperative endoscopy and computed tomography scores were higher in the frontal sinusotomy group (p ? 0.001). Postoperatively, both groups showed comparable SNOT-22 scores with worse endoscopy scores in the frontal sinusotomy group (p = 0.038). Postoperative improvement in SNOT-22 total and subdomain scores was comparable between groups. Nasal endoscopy scores improved to a greater degree in the frontal sinusotomy group (p = 0.023). Duration of postoperative topical steroid use was higher in the frontal sinusotomy group (p = 0.007). Revision surgery was needed in 2.6% of frontal sinusotomy patients and 0% of patients without frontal sinusotomy.The treatment of chronic frontal sinusitis through ethmoidectomy is a potential alternative to frontal sinusotomy achieving similar quality of life (QOL) improvements in patients manifesting less severe sinus disease.

    View details for DOI 10.1002/alr.21726

    View details for Web of Science ID 000379700700007

    View details for PubMedID 26879467

  • Productivity costs decrease after endoscopic sinus surgery for refractory chronic rhinosinusitis. Laryngoscope Rudmik, L., Smith, T. L., Mace, J. C., Schlosser, R. J., Hwang, P. H., Soler, Z. M. 2016; 126 (3): 570-574


    The primary objective of this pilot study was to define the change in productivity costs following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Secondary objectives were to identify CRS-related characteristics that may influence the degree of productivity improvement after ESS.Prospective, multi-institutional, observational cohort study.The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time were quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 US Census and the 2013 US Department of Labor statistics.Twenty-seven patients with refractory CRS who underwent ESS were followed for a mean of 15 months (range, 8-25 months). Following ESS, there were improvements in annual absenteeism (22 days reduced to 3 days), annual presenteeism (41 days reduced to 19 days), and annual household days lost (12 days reduced to 6 days). Overall, the preoperative productivity costs were reduced after ESS ($9,190 vs. $3,373, respectively; P < .001).Daily productivity is negatively impacted by the presence of CRS. The outcomes from this study provide the first insights into the reduced productivity costs associated with receiving ESS for refractory CRS. Future studies with larger sample sizes will need to validate the results from this pilot study.2c Laryngoscope, 126:570-574, 2016.

    View details for DOI 10.1002/lary.25656

    View details for PubMedID 26371457

  • International Consensus Statement on Allergy and Rhinology: Rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Orlandi, R. R., Kingdom, T. T., Hwang, P. H., Smith, T. L., Alt, J. A., Baroody, F. M., Batra, P. S., Bernal-Sprekelsen, M., Bhattacharyya, N., Chandra, R. K., Chiu, A., Citardi, M. J., Cohen, N. A., DelGaudio, J., Desrosiers, M., Dhong, H., Douglas, R., Ferguson, B., Fokkens, W. J., Georgalas, C., Goldberg, A., Gosepath, J., Hamilos, D. L., Han, J. K., Harvey, R., Hellings, P., Hopkins, C., Jankowski, R., Javer, A. R., Kern, R., Kountakis, S., Kowalski, M. L., Lane, A., Lanza, D. C., Lebowitz, R., Lee, H., Lin, S. Y., Lund, V., Luong, A., Mann, W., Marple, B. F., McMains, K. C., Metson, R., Naclerio, R., Nayak, J. V., Otori, N., Palmer, J. N., Parikh, S. R., Passali, D., Peters, A., Piccirillo, J., Poetker, D. M., Psaltis, A. J., Ramadan, H. H., Ramakrishnan, V. R., Riechelmann, H., Roh, H., Rudmik, L., Sacks, R., Schlosser, R. J., Senior, B. A., Sindwani, R., Stankiewicz, J. A., Stewart, M., Tan, B. K., Toskala, E., Voegels, R., Wang, D. Y., Weitzel, E. K., Wise, S., Woodworth, B. A., Wormald, P., Wright, E. D., Zhou, B., Kennedy, D. W. 2016; 6: S22-S209


    Isam Alobid, MD, PhD(1) , Nithin D. Adappa, MD(2) , Henry P. Barham, MD(3) , Thiago Bezerra, MD(4) , Nadieska Caballero, MD(5) , Eugene G. Chang, MD(6) , Gaurav Chawdhary, MD(7) , Philip Chen, MD(8) , John P. Dahl, MD, PhD(9) , Anthony Del Signore, MD(10) , Carrie Flanagan, MD(11) , Daniel N. Frank, PhD(12) , Kai Fruth, MD, PhD(13) , Anne Getz, MD(14) , Samuel Greig, MD(15) , Elisa A. Illing, MD(16) , David W. Jang, MD(17) , Yong Gi Jung, MD(18) , Sammy Khalili, MD, MSc(19) , Cristobal Langdon, MD(20) , Kent Lam, MD(21) , Stella Lee, MD(22) , Seth Lieberman, MD(23) , Patricia Loftus, MD(24) , Luis Macias-Valle, MD(25) , R. Peter Manes, MD(26) , Jill Mazza, MD(27) , Leandra Mfuna, MD(28) , David Morrissey, MD(29) , Sue Jean Mun, MD(30) , Jonathan B. Overdevest, MD, PhD(31) , Jayant M. Pinto, MD(32) , Jain Ravi, MD(33) , Douglas Reh, MD(34) , Peta L. Sacks, MD(35) , Michael H. Saste, MD(36) , John Schneider, MD, MA(37) , Ahmad R. Sedaghat, MD, PhD(38) , Zachary M. Soler, MD(39) , Neville Teo, MD(40) , Kota Wada, MD(41) , Kevin Welch, MD(42) , Troy D. Woodard, MD(43) , Alan Workman(44) , Yi Chen Zhao, MD(45) , David Zopf, MD(46) CONTRIBUTING AUTHOR AFFILIATIONS: (1) Universidad de Barcelona; (2) University of Pennsylvania; (3) Louisiana State University Health Sciences Center; (4) Universidade de São Paulo; (5) ENT Specialists of Illinois; (6) University of Arizona; (7) University of Oxford; (8) University of Texas; (9) University of Indiana; (10) Mount Sinai Beth Israel; (11) Emory University; (12) University of Colorado; (13) Wiesbaden, Germany; (14) University of Colorado; (15) University of Alberta; (16) University of Alabama at Birmingham; (17) Duke University; (18) Sungkyunkwan University; (19) University of Pennsylvania; (20) Universidad de Barcelona; (21) Northwestern University; (22) University of Pittsburgh; (23) New York University; (24) Emory University; (25) University of British Columbia; (26) Yale University School of Medicine; (27) Private Practice; (28) Department of Otolaryngology, Hôtel-Dieu Hospital, Centre de Recherche du Centre Hospitalier de l'Université de Montréal; (29) University of Adelaide; (30) Pusan National University; (31) University of California, San Francisco; (32) University of Chicago; (33) University of Auckland; (34) Johns Hopkins University; (35) University of New South Wales, Australia; (36) Stanford University; (37) Washington University; (38) Harvard Medical School; (39) Medical University of South Carolina; (40) Singapore General Hospital; (41) Taho University; (42) Northwestern University; (43) Cleveland Clinic Foundation; (44) University of Pennsylvania; (45) University of Adelaide; (46) University of Michigan.

    View details for DOI 10.1002/alr.21695

    View details for Web of Science ID 000371151900002

    View details for PubMedID 26889651

  • International Consensus Statement on Allergy and Rhinology: Rhinosinusitis Executive Summary. International forum of allergy & rhinology Orlandi, R. R., Kingdom, T. T., Hwang, P. H. 2016; 6: S3-S21


    The body of knowledge regarding rhinosinusitis (RS) continues to expand, with rapid growth in number of publications yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). This executive summary consolidates the findings of the ICAR:RS document.ICAR:RS presents over 140 topics in the forms of evidence-based reviews with recommendations (EBRRs) and evidence-based reviews (EBR). The structured recommendations of the EBRR sections are summarized in this executive summary.This summary compiles the EBRRs regarding medical and surgical management of acute RS (ARS) and chronic RS with and without nasal polyps (CRSwNP and CRSsNP).This ICAR:RS Executive Summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

    View details for DOI 10.1002/alr.21694

    View details for PubMedID 26878819

  • Indications and outcomes for Draf IIB frontal sinus surgery AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Turner, J. H., Vaezeafshar, R., Hwang, P. H. 2016; 30 (1): 70-73


    Extended frontal surgery techniques are often required when maximal medical therapy and standard endoscopic surgical approaches fail in patients. Although outcomes of the Draf III (modified Lothrop) procedure have been widely reported, postoperative outcomes and indications for the Draf IIB frontal sinusotomy have been relatively underreported. We presented our institution's experience with the Draf IIB procedure.Patients who underwent the Draf IIB frontal sinusotomy between 2007 and 2012 were identified by retrospective chart review. Data collected included demographics, imaging, sinus patency, and Sino-nasal Outcome Test 20 scores.A total of 22 Draf IIB frontal sinusotomies were performed in 18 patients. Thirteen of eighteen patients had previous frontal sinus surgery. The most common indications for the extended approach were chronic frontal sinusitis due to lateralized middle turbinate remnant (8 patients), mucocele (6), postoperative synechiae (5), and frontal sinus mass (3). Sinus ostium patency was maintained in 20 of 22 sinuses over an average follow-up period of 16.2 months. No complications were reported.The Draf IIB frontal sinusotomy is a relatively safe procedure, with multiple indications. Long-term sinus ostium patency was maintained in >90% of operated sinuses, which indicated that the Draf IIB procedure may present an acceptable alternative to more aggressive extended frontal sinus approaches in selected patients.

    View details for DOI 10.2500/ajra.2016.30.4268

    View details for Web of Science ID 000370446800013

    View details for PubMedID 26867534

  • Giant Prolactinoma Presenting with Neck Pain and Structural Compromise of the Occipital Condyles. Journal of neurological surgery reports Yecies, D., Ajlan, A., Ratliff, J., Ziskin, J., Hwang, P., Vogel, H., Katznelson, L., Harsh, G. 2015; 76 (2): e297-301


    Prolactinomas are the most common form of endocrinologically active pituitary adenoma; they account for ? 45% of pituitary adenomas encountered in clinical practice. Giant adenomas are those?>?4 cm in diameter. Less than 0.5% of pituitary adenomas encountered in neurosurgical practice are giant prolactinomas. Patients with giant prolactinomas typically present with highly elevated prolactin levels, endocrinologic disturbances, and neurologic symptoms from mass-induced pressure. Described here is an unusual case of a giant prolactinoma presenting with neck pain and structural compromise of the occipital condyles. Transnasal biopsy of the nasopharyngeal portion of the mass obtained tissue consistent with an atypical prolactinoma with p53 reactivity and a high Ki-67 index of 5%. Despite the size and invasiveness of the tumor, the patient had resolution of his clinical symptoms, dramatic reduction of his hyperprolactinemia, and near-complete disappearance of his tumor following medical treatment.

    View details for DOI 10.1055/s-0035-1566124

    View details for PubMedID 26623246

  • C Perioperative Management of Antithrombotic Therapy in Common Otolaryngologic Surgical Procedures: State of the Art Review OTOLARYNGOLOGY-HEAD AND NECK SURGERY Hsueh, W. D., Hwang, P. H., Abuzeid, W. M. 2015; 153 (4): 493-503


    The perioperative management of patients undergoing otolaryngologic procedures is increasingly complicated by the use of newer antithrombotic agents. Furthermore, with advances in anesthesia and surgical technique, otolaryngologists are presented with the challenge of operating on patients with advanced comorbid diseases. The objective of this review is to provide evidence-based recommendations on perioperative antithrombotic management for common otolaryngologic procedures.PubMed/MEDLINE.Selected literature on patient-specific thromboembolic risk, rate of bleeding complications in otolaryngologic procedures, and the interruption of antithrombotic therapy is reviewed and interpreted by expert opinion.By stratifying patients into either low thromboembolic risk (? 5%) or high thromboembolic risk (> 5%) and interpreting this in the context of procedural bleed risk and potential clinical consequences in the event of a bleed, otolaryngologists can make evidence-based decisions to determine the appropriate perioperative management of antithrombotic therapy.When the perioperative management of antithrombotic therapy is being decided, 3 critical factors must be considered systematically: the patient's inherent thromboembolic risk, the risk and potential consequences of bleeding related to the procedure, and the timing of interruption of thromboembolic therapy.

    View details for DOI 10.1177/0194599815600409

    View details for Web of Science ID 000362445800006

    View details for PubMedID 26307580

  • Secretion rates of human nasal submucosal glands from patients with chronic rhinosinusitis or cystic fibrosis. American journal of rhinology & allergy Jeong, J. H., Hwang, P. H., Cho, D., Joo, N. S., Wine, J. J. 2015; 29 (5): 334-338


    A majority of patients with cystic fibrosis (CF) have chronic rhinosinusitis (CRS) and/or nasal polyps, both of which may be secondary to reduced fluid secretion from nasal submucosal glands.To determine whether decreased fluid secretion from nasal submucosal glands also occurs in patients without CF and with CRS.Inferior turbinates of the nasal cavity were harvested from controls, subjects with CRS, and subjects with CF (n = 5-7 per group). The secretion rates of the nasal submucosal glands of the three groups in response to carbachol and forskolin were measured by using time lapse digital imaging of mucus bubbles from single glands as they formed on the mucosal surface under oil.Carbachol-stimulated secretion rates were the following: controls, 1670 ± 381 pl·min(-1)·gland(-1); CRS, 965 ± 440 pl·min(-1)·gland(-1); and CF, 933 ± 588 pl·min(-1)·gland(-1) (p = 0.23, Kruskal-Wallis test). Forskolin-stimulated secretion rates were the following: controls, 229 ± 14 pl·min(-1)·gland(-1); CRS, 154 ± 48 pl·min(-1)·gland(-1); and CF, 22 ± 15 pl·min(-1)·gland(-1) (p = 0.008, Kruskal-Wallis test). The ratio of the average secretion rate induced by forskolin to that induced by carbachol was 13.7% in the controls, and 15.9% in CRS and 2.3% in CF groups.The only significant difference in this small study was decreased forskolin-stimulated secretion in subjects with CF relative to the other subjects. However, there was a trend toward reduced carbachol-stimulated secretion rates in subjects with CRS and with and without CF relative to controls. Additional studies are needed to determine if nasal submucosal gland hyposecretion occurs in CRS either as a contributor to or as a consequence of CRS pathogenesis.

    View details for DOI 10.2500/ajra.2015.29.4213

    View details for PubMedID 26358343

  • Secretion rates of human nasal submucosal glands from patients with chronic rhinosinusitis or cystic fibrosis AMERICAN JOURNAL OF RHINOLOGY & ALLERGY Jeong, J. H., Hwang, P. H., Cho, D., Joo, N. S., Wine, J. J. 2015; 29 (5): 334-338

    View details for DOI 10.2500/ajra.2015.29.4213

    View details for Web of Science ID 000364337200011

    View details for PubMedID 26358343

  • Medical therapy vs surgery for recurrent acute rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (8): 667-673

    View details for DOI 10.1002/alr.21533

    View details for Web of Science ID 000359053700002

    View details for PubMedID 25950995

  • Medical therapy vs surgery for recurrent acute rhinosinusitis. International forum of allergy & rhinology Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (8): 667-673


    Treatment indications for recurrent acute rhinosinusitis (RARS) remain poorly defined. We studied outcomes of medical vs surgical treatment of RARS, anatomic variants associated with RARS, and factors predicting crossover from medical to surgical treatment.A total of 220 RARS patients treated between 2006 and 2014 were retrospectively divided into 3 cohorts: medical only (MED); surgical only (SURG); or medical crossing over into surgical (CROSS). Twenty-two item Sino-Nasal Outcome Test (SNOT-22) scores, modified Lund-Kennedy endoscopy scores, and prevalence of anatomic variants by computed tomography (CT) were compared. A total of 220 CT scans obtained for non-sinus indications served as controls. A logistic regression model was used for analysis.The mean baseline SNOT-22 scores for all cohorts were similar (MED = 48, SURG = 49, CROSS = 45, p < 0.0001). The SURG cohort showed greater reduction of SNOT-22 scores compared to the MED cohort at 3, 6, and 12 months follow-up (p < 0.0001). The crossover cohort converted to surgery after escalation of SNOT-22 score by a mean of 15 points (p < 0.03), and showed significant reduction postoperatively (p < 0.0001). Haller cell (odds ratio [OR] 3.9; p < 0.0001), concha bullosa (OR 3.7; p < 0.003), and accessory ostium (OR 2.2; p < 0.01) were more common in the entire RARS group vs controls; however, there were no inter-cohort differences in prevalence.RARS patients can benefit from both medical and surgical treatment strategies, but surgical treatment results in greater symptomatic improvement compared to medical treatment. Patients cross over from medical to surgical treatment when SNOT-22 scores escalate by a mean of 15 points. Haller cell, concha bullosa, and accessory ostium are associated with RARS but are equally common in medical, surgical, and crossover cohorts.

    View details for DOI 10.1002/alr.21533

    View details for PubMedID 25950995

  • The impact of diabetes mellitus on outcomes of endoscopic sinus surgery: a nested case-control study. International forum of allergy & rhinology Hajjij, A., Mace, J. C., Soler, Z. M., Smith, T. L., Hwang, P. H. 2015; 5 (6): 533-540


    Given the immune impairment associated with diabetes mellitus (DM), its impact on chronic rhinosinusitis (CRS) is a potentially relevant concern; however, it has not been well-studied. A single retrospective study reported worse postoperative quality of life outcomes in DM patients with CRS. Our study evaluated the effect of comorbid DM on outcomes of endoscopic sinus surgery (ESS) using a prospective study design.Using a multicentered, prospective cohort of patients (n = 437) undergoing ESS for recalcitrant CRS, a nested case-control comparison was performed between 20 adult DM patients (cases) and 20 non-DM patients (controls), matched 1:1 for age and Lund-Mackay computed tomography (CT) scores. Outcome measures included 22-item Sinonasal Outcome Test (SNOT-22), Rhinosinusitis Disability Index (RSDI), Patient Health Questionnaire (PHQ-2), and Brief Smell Identification Test (BSIT).Mean follow-up was similar between cases (mean ± standard deviation: 12.6 ± 6.0 months) and controls (12.9 ± 5.9 months; p = 0.862). All preoperative scores were statistically equivalent between DM and non-DM cohorts. Both cohorts showed significant post-ESS improvement in SNOT-22 (p = 0.001) and RSDI scores (p < 0.001), and no significant change in PHQ-2 or BSIT scores. The magnitude of score changes was statistically equivalent between the 2 cohorts for all outcome measures with no differences in postoperative score changes between insulin-dependent DM patients and those managed by oral hypoglycemics or dietary restriction (p ? 0.444).DM patients with CRS experience similar degrees of symptomatic benefit from ESS compared to controls. Insulin dependence does not appear to adversely affect surgical outcome but a larger cohort would better assess the effect of DM type and control on surgical outcomes in CRS.

    View details for DOI 10.1002/alr.21495

    View details for PubMedID 25913815

  • The impact of diabetes mellitus on outcomes of endoscopic sinus surgery: a nested case-control study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Hajjij, A., Mace, J. C., Soler, Z. M., Smith, T. L., Hwang, P. H. 2015; 5 (6): 533-540

    View details for DOI 10.1002/alr.21495

    View details for Web of Science ID 000355860600011

    View details for PubMedID 25913815

  • Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis. International forum of allergy & rhinology Huang, Z., Hajjij, A., Li, G., Nayak, J. V., Zhou, B., Hwang, P. H. 2015; 5 (4): 303-309


    Neo-osteogenesis of the paranasal sinuses is a radiologic finding of unclear clinical significance. Although current evidence suggests that these bony changes represent an inflammatory response rather than an infectious osteitis, bacteria associated with the sinonasal mucosa may induce inflammatory mediators as a mechanism of neo-osteogenesis. The objectives of this study were (1) to determine whether there is an association between bacteria isolated on sinus culture and neo-osteogenesis, and (2) to identify other predictive factors for neo-osteogenesis.Ninety patients undergoing sinus surgery for medically refractory CRS were recruited. Radiologic evidence of neo-osteogenesis was assessed by the Global Osteitis Scoring Scale (GOSS) and mucosal disease severity was assessed by the Lund-Mackay score (LMS). Bacterial culture was obtained endoscopically at the preoperative office visit or during surgery. Multiple and logistic regression models were used to evaluate the association between the types of bacterial species isolated, number of previous surgeries, and severity of neo-osteogenesis.Thirty of the 90 (33.3%) patients had radiologic evidence of neo-osteogenesis. Pseudomonas aeruginosa was significantly associated with neo-osteogenesis (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.12 to 13.56), whereas Staphylococcus aureus was not. The number of previous surgeries, especially 2 or more previous surgeries, was associated with the extent of neo-osteogenesis (OR, 3.48; 95% CI, 1.14 to 10.51). The LMS was also significantly associated with the extent of neo-osteogenesis.The presence of P. aeruginosa in the sinuses is an independent predictor of neo-osteogenesis, whereas S. aureus is not. The number of previous surgeries and the LMS are also independently associated with the severity of neo-osteogenesis.

    View details for DOI 10.1002/alr.21485

    View details for PubMedID 25644047

  • The effects of topical agents on paranasal sinus mucosa healing: a rabbit study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Jain, R., Kim, R., Waldvogel-Thurlow, S., Hwang, P., Cornish, J., Douglas, R. 2015; 5 (4): 310-317


    Numerous topical agents have been used intraoperatively to enhance postoperative mucosal healing or reduce scar formation. However, the histological effects of many of these treatments have not been well described. This study investigates the impact of topical mometasone furoate, acitretin, lactoferrin, and Silastic sheet (Medtronic) on sinus mucosal healing in a rabbit model.Forty-eight New Zealand white rabbits underwent defined, localized stripping of a bilateral region of maxillary sinus mucosa. One of 6 treatments was placed in 1 maxillary sinus, and the treatment carrier was applied contralaterally (0.1% mometasone furoate, 0.25% and 0.5% acitretin, lactoferrin, Silastic, and no treatment; n = 8 each group). Rabbits were euthanized after 2 weeks and histological sections were examined with light microscopy.Treatment with acitretin 0.25% and 0.5% improved cilial recovery by 0.9 ± 0.5 (p = 0.003) and 0.5 ± 0.5 (p < 0.05), respectively. Acitretin 0.25% treatment also significantly reduced collagen in healing mucosa (5.1% ± 4.8%, p = 0.04). Conversely, rabbits treated with mometasone furoate 0.1% were more likely to have reduced cilial and goblet cell recovery. Intergroup comparisons demonstrated a significant improvement in cilial recovery scores with both acitretin doses compared with mometasone furoate (p < 0.05) and less collagen deposition in rabbits treated with placebo gel over Silastic (p < 0.05). Mucosa directly underlying a blood clot had a lower cilia score and impaired epithelial recovery (p < 0.001).Intraoperatively applied agents have the potential to significantly affect wound healing. Acitretin improved cilial recovery and reduced collagen deposition.

    View details for DOI 10.1002/alr.21470

    View details for Web of Science ID 000352580700008

    View details for PubMedID 25677963

  • Clinical predictors of neo-osteogenesis in patients with chronic rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Huang, Z., Hajjij, A., Li, G., Nayak, J. V., Zhou, B., Hwang, P. H. 2015; 5 (4): 303-309

    View details for DOI 10.1002/alr.21485

    View details for Web of Science ID 000352580700007

    View details for PubMedID 25644047

  • Meningiomas of the tuberculum and diaphragma sellae. Journal of neurological surgery. Part B, Skull base Ajlan, A. M., Choudhri, O., Hwang, P., Harsh, G. 2015; 76 (1): 74-79


    Introduction?Although tuberculum sellae (TS) and diaphragma sellae (DS) meningiomas have different anatomical origins, they are frequently discussed as a single entity. Here we review the radiologic and intraoperative findings of TS and DS meningiomas and propose a radiologic classification. Methods?We retrospectively reviewed 10 consecutive TS and DS meningiomas. Data regarding clinical presentation, preoperative imaging, and intraoperative findings were analyzed. Three sellar dimensions were measured on magnetic resonance imaging (MRI): the tuberculum-sellar floor interval (TSFI), the planum-tuberculum interval (PTI), and the total height. Results?Three distinct anatomical patterns were recognized: exclusively tubercular meningiomas (type A) were accompanied by elongation of the TSFI and, more significantly, of the PTI; combined TS and DS meningiomas (type B) were associated with relative elongation of both the PTI and TSFI; and the sole exclusively DS meningioma (type C) was associated with elongation of neither PTI nor TSFI. Conclusion?Suprasellar meningiomas can be classified as tubercular, combined, or diaphragmatic based on preoperative MRI. Exclusively tubercular meningiomas (type A) require only a supradiaphragmatic approach. Tumor involvement of the sellar diaphragm (type B or C) requires resection of the diaphragm and thus a combined infra- and supradiaphragmatic approach.

    View details for DOI 10.1055/s-0034-1390400

    View details for PubMedID 25685653

  • Meningiomas of the tuberculum and diaphragma sellae. Journal of neurological surgery. Part B, Skull base Ajlan, A. M., Choudhri, O., Hwang, P., Harsh, G. 2015; 76 (1): 74-79

    View details for DOI 10.1055/s-0034-1390400

    View details for PubMedID 25685653

  • Long-term outcomes of endoscopic maxillary mega-antrostomy for refractory chronic maxillary sinusitis. International forum of allergy & rhinology Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (1): 60-65


    Endoscopic maxillary mega-antrostomy (EMMA) is a revision surgical procedure for recalcitrant maxillary sinusitis in which medical therapy and endoscopic antrostomy have been unsuccessful. In 2008 our group published favorable outcomes of EMMA in 28 patients with relatively short follow-up and nonvalidated outcome measures. This study reports an update of long-term outcomes of this same cohort, as well as outcomes of an interval cohort of 94 patients using validated outcome measures.Retrospective review was performed for 122 patients (163 sides) who underwent EMMA between 2005 and 2013. For the original 2008 cohort, the original questionnaire from 2008 was readministered by telephone interview. For the interval cohort, preoperative and postoperative SNOT-22 symptom scores and modified Lund-Kennedy endoscopic scores were compared.The original 2008 cohort of 28 patients, now with a mean follow-up period of 6.9 years, demonstrated sustained improvement of symptoms. The outcomes were statistically comparable to the 2008 study, with 72.4% reporting complete or significant improvement, 27.6% reporting partial improvement, and 0% reporting worsening.

    View details for DOI 10.1002/alr.21407

    View details for PubMedID 25312656

  • Long-term outcomes of endoscopic maxillary mega-antrostomy for refractory chronic maxillary sinusitis. International forum of allergy & rhinology Costa, M. L., Psaltis, A. J., Nayak, J. V., Hwang, P. H. 2015; 5 (1): 60-65

    View details for DOI 10.1002/alr.21407

    View details for PubMedID 25312656

  • Steroid-eluting sinus stents for improving symptoms in chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery COCHRANE DATABASE OF SYSTEMATIC REVIEWS Huang, Z., Hwang, P., Sun, Y., Zhou, B. 2015


    Functional endoscopic sinus surgery (FESS) has become a well-established approach for treating patients with chronic rhinosinusitis (CRS) refractory to medical management. However, the surgical outcome may be compromised by postoperative inflammation, polyposis and adhesions, which often require subsequent intervention. Bioabsorbable, steroid-eluting sinus stents are inserted into the nose, sinuses or both following surgery to prevent stenosis of the sinus openings during the postoperative healing period. The slow release of corticosteroid aims to decrease mucosal oedema and expedite wound healing. Whether a steroid-eluting stent offers any beneficial effects in terms of improving sinonasal symptoms has not been systematically reviewed.To assess the safety and efficacy of steroid-eluting sinus stent placement in CRS patients after FESS.The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 4); PubMed; EMBASE; CINAHL; Web of Science;; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 May 2015.We included all randomised controlled trials (RCTs) comparing steroid-eluting sinus stents with non-steroid-eluting sinus stents, nasal packing or no treatment in adult CRS patients undergoing FESS.We used the standard methodological procedures expected by The Cochrane Collaboration.We identified no RCTs that met our inclusion criteria. Among the 159 records retrieved using our search strategy, 21 trials had the potential to be included given that they had tested sinus stents, spacers and packing materials for patients with CRS undergoing FESS. However, we excluded these trials from the review because they met some but not all of the inclusion criteria.We are unable to provide evidence to establish whether steroid-eluting sinus stents have potential advantages and disadvantages for patients with CRS undergoing FESS. Future, high-quality RCTs are needed to assess whether or not steroid-eluting sinus stents confer any beneficial effects, over those of surgery alone, when compared to non-steroid sinus stents.

    View details for DOI 10.1002/14651858.CD010436.pub2

    View details for Web of Science ID 000357606400056

    View details for PubMedID 26068957

  • Complications associated with the pedicled nasoseptal flap for skull base reconstruction. Laryngoscope Soudry, E., Psaltis, A. J., Lee, K. H., Vaezafshar, R., Nayak, J. V., Hwang, P. H. 2015; 125 (1): 80-85


    To analyze complications associated with nasoseptal flap elevation and reconstruction in endoscopic skull base surgery.Case series.Retrospective chart review of all patients who underwent nasoseptal flap procedure in our institution between 2008 and 2013.A total of 121 patients were identified with a mean follow-up time of 10.4 months. Complications associated with this procedure occurred in 33 patients (27%). The majority of complications were related to the septal donor site and included septal perforation, cartilage necrosis, and prolonged crusting. Other complications included intraoperative injury to the flap pedicle (n?=?4) or recurrent/persistent cerebrospinal fluid leak occurring in the early postoperative period (n?=?7). Long-term quality-of-life data assessed via Sinonasal Outcome Test-22 questionnaires did not reveal notable differences when compared to preoperative scores.The complication rate associated with nasoseptal flap elevation and inset is higher than previously described. The majority of complications became manifest beyond the immediate postoperative period and were associated with the septal donor site, including septal perforation, prolonged crusting, and cartilage necrosis. We hypothesize that donor site morbidity may be related to compromise of the contralateral septal vascular supply during the procedure. The range and frequency of complications of nasal septal flap surgery should be considered in counseling patients who may receive a nasoseptal flap for skull base reconstruction.4. Laryngoscope, 125:80-85, 2015.

    View details for DOI 10.1002/lary.24863

    View details for PubMedID 25111727

  • Air pollutants cause release of hydrogen peroxide and interleukin-8 in a human primary nasal tissue culture model. International forum of allergy & rhinology Cho, D., Le, W., Bravo, D. T., Hwang, P. H., Illek, B., Fischer, H., Nayak, J. V. 2014; 4 (12): 966-971


    A component of primary innate defense of the nasal mucosa against inhaled pathogens includes continuous, low-level release of hydrogen peroxide (H2 O2 ) into luminal secretions. Epidemiologically, an association exists between poor air quality and increased prevalence of sinonasal disease. To understand the effects of particulate matter (PM) in nasal mucosa, we studied the release of H2 O2 and interleukin 8 (IL-8) after PM exposure.Human nasal specimens were collected from surgery and cultured in serum-free growth medium. Cell integrity and recovery during culture was monitored by lactate dehydrogenase (LDH) release into the medium. Cultures were exposed to PM for 24 hours in the presence/absence of diphenyleneiodonium sulfate (DPI; a nicotinamide adenine dinucleotide phosphate [NADPH] oxidase inhibitor). Luminex cytokine and Amplex-Red H2 O2 assays were performed.LDH levels dropped rapidly within 2 days, indicative of stabilization and cell recovery after harvest. All cultures released H2 O2 into the medium. Exposure to PM (20 ?g/cm(2) ) increased H2 O2 levels significantly (94.6 ± 7.7 nM) compared to untreated controls (55.8 ± 4.0 nM; p = 0.001). PM-induced H2 O2 production was partially inhibited by DPI (80.1 ± 3.8nM), indicating that cellular NADPH oxidase may be a primary source of H2 O2 production. Exposure to PM increased IL-8 levels in a dose-dependent fashion (control = 2301 ± 412 MFI; 20 ?g/cm(2) = 5002 ± 1327 MFI; 40 ?g/cm(2) = 8219 ± 1090 MFI; p = 0.022).PM increases the quantity of H2 O2 released by nasal epithelial cells, indicating that PM can contribute to oxidative stress in part by activating a normal cellular defense mechanism. Exposure to PM resulted in elevated IL-8 levels and mucin production in explants. Efforts to reduce airborne PM may lead to reduced H2 O2 and mucin production in sinonasal epithelium.

    View details for DOI 10.1002/alr.21413

    View details for PubMedID 25400124

  • Air pollutants cause release of hydrogen peroxide and interleukin-8 in a human primary nasal tissue culture model INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Cho, D., Le, W., Bravo, D. T., Hwang, P. H., Illek, B., Fischer, H., Nayak, J. V. 2014; 4 (12): 966-971

    View details for DOI 10.1002/alr.21413

    View details for Web of Science ID 000346022600004

    View details for PubMedID 25400124

  • SNOT-22 quality of life domains differentially predict treatment modality selection in chronic rhinosinusitis INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY DeConde, A. S., Mace, J. C., Bodner, T., Hwang, P. H., Rudmik, L., Soler, Z. M., Smith, T. L. 2014; 4 (12): 972-979

    View details for DOI 10.1002/alr.21408

    View details for Web of Science ID 000346022600005

    View details for PubMedID 25323055

  • SNOT-22 quality of life domains differentially predict treatment modality selection in chronic rhinosinusitis. International forum of allergy & rhinology DeConde, A. S., Mace, J. C., Bodner, T., Hwang, P. H., Rudmik, L., Soler, Z. M., Smith, T. L. 2014; 4 (12): 972-979


    Prior study demonstrated that baseline 22-item Sino-Nasal Outcome Test (SNOT-22) aggregate scores accurately predict selection of surgical intervention in patients with chronic rhinosinusitis (CRS). Factor analysis of the SNOT-22 survey has identified five distinct domains that are differentially impacted by endoscopic sinus surgery (ESS). This study sought to quantify SNOT-22 domains in patient cohorts electing both surgical or medical management and postinterventional change in these domains.CRS patients were prospectively enrolled into a multi-institutional, observational cohort study. Subjects elected continued medical management or ESS. SNOT-22 domain scores at baseline were compared between treatment cohorts. Postintervention domain score changes were evaluated in subjects with at least six-month follow-up.A total of 363 subjects were enrolled with 72 (19.8%) electing continued medical management, whereas 291 (80.2%) elected ESS. Baseline SNOT-22 domain scores were comparable between treatment cohorts in sinus-specific domains (rhinologic, extranasal rhinologic, and ear/facial symptoms; p > 0.050); however, the surgical cohort reported significantly higher psychological (mean ± standard deviation [SD]: 16.0 ± 8.4 vs 12.0 ± 7.1; p < 0.001) and sleep dysfunction (13.7 ± 6.8 vs 10.5 ± 6.2; p < 0.001) than the medical cohort. Effect sizes for ESS varied across domains with rhinologic and extranasal rhinologic symptoms experiencing the greatest gains (1.067 and 0.997, respectively), whereas psychological and sleep dysfunction experiencing the smallest improvements (0.805 and 0.818, respectively). Patients experienced greater mean improvements after ESS in all domains compared to medical management (p < 0.001).Subjects electing ESS report higher sleep and psychological dysfunction compared to medical management but have comparable sinus-specific symptoms. Subjects undergoing ESS experience greater gains compared to medical management across all domains; however, these gains are smallest in the psychological and sleep domains.

    View details for DOI 10.1002/alr.21408

    View details for PubMedID 25323055

  • Endoscopic resection of a giant intradural retroclival ecchordosis physaliphora: surgical technique and literature review. World neurosurgery Choudhri, O., Feroze, A., Hwang, P., Vogel, H., Ajlan, A., Harsh, G. 2014; 82 (5): 912 e21-6


    To report the first complete resection of a giant ecchordosis physaliphora using an endoscopic transclival approach and to provide a current review of the literature.This rare benign lesion, originating from embryonic notochordal remnants, was located in the prepontine cistern of a 63-year-old man presenting with progressive tremor and imbalance. Preoperative imaging demonstrated a 2.1-cm intradural lesion abutting the pons and basilar artery and extending through the dura mater.A gross total resection was successfully achieved endoscopically without neurovascular compromise or additional complications. Postoperative histopathologic examination was consistent with a diagnosis of giant ecchordosis physaliphora.An endoscopic endonasal transclival approach provided a direct, minimally invasive route for safe and complete resection of this rare prepontine tumor, as it has for similarly located skull base chordomas. Our experience highlights the utility of endoscopy in visualization of both pathologic entities and nearby critical neurovascular structures in the management of ecchordosis physaliphora and other cranial base neoplasms.

    View details for DOI 10.1016/j.wneu.2014.06.019

    View details for PubMedID 24937599

  • Endoscopic resection of a giant intradural retroclival ecchordosis physaliphora: surgical technique and literature review. World neurosurgery Choudhri, O., Feroze, A., Hwang, P., Vogel, H., Ajlan, A., Harsh, G. 2014; 82 (5): 912 e21-6

    View details for DOI 10.1016/j.wneu.2014.06.019

    View details for PubMedID 24937599

  • Management of frontal sinus fractures: treatment modality changes at a level I trauma center. journal of craniofacial surgery Fox, P. M., Garza, R., Dusch, M., Hwang, P. H., Girod, S. 2014; 25 (6): 2038-2042


    The optimal management of frontal sinus fractures remains controversial, and previously accepted indications for surgical intervention are being challenged. The goals of this study were to determine how frontal sinus fracture management has changed at a single institution across multiple disciplines and to evaluate the long-term outcomes of operative and nonoperative treatment modalities.Patients treated for a frontal sinus fracture at Stanford Hospital and Clinics between June 1998 and June 2009 were included in the study. Inpatient records, clinic notes, operative reports, and radiographic studies were reviewed. The patients were invited for a follow-up clinic visit, physical examination, and focused sinus computed tomography. For a period of 11 years, 124 patients were treated for a frontal sinus fracture by physicians from 3 surgical subspecialties: otolaryngology, plastic surgery, and neurosurgery. A low short-term complication rate was observed (5.6%), and there was a trend toward nonsurgical management within the study population. Ten patients returned for a long-term follow-up. Of these, the 2 patients who underwent cranialization experienced as many or more long-term complications compared with the patients treated by other modalities. These complications included abnormal frontal bone contour with bony discontinuity and altered sensation in the distribution of the trigeminal nerve.The demonstrated trend toward nonsurgical management of frontal sinus fractures seems to be safe. In the limited group of patients who returned for follow-up, more long-term complications were observed in the patients who underwent cranialization. However, a larger long-term follow-up cohort will be necessary to elucidate the relationship between treatment modality and long-term outcomes and complications.

    View details for DOI 10.1097/SCS.0000000000001105

    View details for PubMedID 25377963

  • Management of Frontal Sinus Fractures: Treatment Modality Changes at a Level I Trauma Center JOURNAL OF CRANIOFACIAL SURGERY Fox, P. M., Garza, R., Dusch, M., Hwang, P. H., Girod, S. 2014; 25 (6): 2038-2042
  • Spontaneous Sphenoid Wing Meningoencephaloceles with Lateral Sphenoid Sinus Extension: The Endoscopic Transpterygoid Approach JOURNAL OF NEUROLOGICAL SURGERY PART B-SKULL BASE Ajlan, A., Achrol, A., Soudry, E., Hwang, P. H., Harsh, G. 2014; 75 (5): 314-323
  • Modification of the Lund-Kennedy endoscopic scoring system improves its reliability and correlation with patient-reported outcome measures. Laryngoscope Psaltis, A. J., Li, G., Vaezeafshar, R., Cho, K., Hwang, P. H. 2014; 124 (10): 2216-2223


    To compare three existing endoscopic scoring systems and a newly proposed modified scoring system for the assessment of patients with chronic rhinosinusitis (CRS).Blinded, prospective cohort study.CRS patients completed two patient-reported outcome measures (PROMs)-the visual analogue scale (VAS) symptom score and the Sino-Nasal Outcome Test-22 (SNOT-22)-and then underwent a standardized, recorded sinonasal endoscopy. Videos were scored by three blinded rhinologists using three scoring systems: the Lund-Kennedy (LK) endoscopic score; the Discharge, Inflammation, Polyp (DIP) score; and the Perioperative Sinonasal Endoscopic score. The videos were further scored using a modified Lund-Kennedy (MLK) endoscopic scoring system, which retains the LK subscores of polyps, edema, and discharge but eliminates the scoring of scarring and crusting. The systems were compared for test-retest and inter-rater reliability as well as for their correlation with PROMs.One hundred two CRS patients were enrolled. The MLK system showed the highest inter-rater and test-retest reliability of all scoring systems. All systems except for the DIP correlated with total VAS scores. The MLK was the only system that correlated with the symptom subscore of the SNOT-22 in both unoperated and postoperative patients.Modification of the LK system by excluding the subscores of scarring and crusting improves its reliability and its correlation with PROMs. In addition, the MLK system retains the familiarity of the widely used LK system and is applicable to any patient irrespective of surgical status. The MLK system may be a more suitable and reliable endoscopic scoring system for clinical practice and outcomes research.

    View details for DOI 10.1002/lary.24654

    View details for PubMedID 24615873

  • Spontaneous sphenoid wing meningoencephaloceles with lateral sphenoid sinus extension: the endoscopic transpterygoid approach. Journal of neurological surgery. Part B, Skull base Ajlan, A., Achrol, A., Soudry, E., Hwang, P. H., Harsh, G. 2014; 75 (5): 314-323


    Spontaneous meningoencephalocele (SME) of the sphenoid wing is a rare cause of cerebrospinal fluid (CSF) leakage. Surgical closure of the fistula is usually required. The approach taken depends on the location of the defect and the extension of the meningoencephalocele. The endoscopic transpterygoid approach may be useful. We prospectively analyzed the three cases of SME of the sphenoid wing with lateral sphenoid sinus extension treated endoscopically at Stanford over the last 3 years with regard to imaging findings, operative technique, and operative morbidity. In our three cases, the extent of pterygopalatine fossa (PPF) exposure undertaken, complete in one and partial in two, depended on the defect site. Follow-up ranged from 17 to 25 months. The fistula was completely closed in all three cases. Extant literature reports a 97% rate of successful closure (N?=?65 of 67, with a mean follow-up of 25 months) and no major complications. Endoscopic transpterygoid repair is a useful, safe alternative to traditional approaches for repair of SME of the sphenoid wing. Its feasibility depends on the site of the defect, which can be identified by preoperative imaging. Larger PPF exposure and postoperative lumbar drainage of CSF can be useful and have a low risk of morbidity.

    View details for DOI 10.1055/s-0034-1372465

    View details for PubMedID 25302142

  • Long-term Sinonasal Outcomes of Aspirin Desensitization in Aspirin Exacerbated Respiratory Disease OTOLARYNGOLOGY-HEAD AND NECK SURGERY Cho, K., Soudry, E., Psaltis, A. J., Nadeau, K. C., McGhee, S. A., Nayak, J. V., Hwang, P. H. 2014; 151 (4): 575-581


    This study aimed to assess sinonasal outcomes in patients with aspirin exacerbated respiratory disease (AERD) undergoing aspirin desensitization following endoscopic sinus surgery (ESS).Case series with chart review.University hospital.A retrospective review of sinonasal outcomes was conducted for 30 AERD patients undergoing aspirin desensitization and maintenance therapy following ESS. Sinonasal outcomes were prospectively assessed by the Sinonasal Outcomes Test-22 (SNOT-22) and endoscopic polyp grading system. Data were collected preoperatively, 1 and 4 weeks postsurgery (before desensitization), and 1, 6, 12, 18, 24, and 30 months after aspirin desensitization.Twenty-eight of 30 patients (93.3%) successfully completed aspirin desensitization, whereas 2 of 30 (6.7%) were unable to complete desensitization due to respiratory intolerance. Of the 21 patients who successfully completed a minimum of 24 weeks of follow-up, 20 (95.2%) patients demonstrated sustained endoscopic and symptomatic improvement for a median follow-up period of 33 months. After surgical treatment but before desensitization, patients experienced significant reductions in SNOT-22 and polyp grade scores. In the first 6 months after aspirin desensitization, patients experienced further significant reductions in SNOT-22 scores, whereas polyp grade remained stable. The improvements in symptom endoscopic scores were preserved throughout the follow-up period after desensitization. No patients required additional sinus surgery. One patient had to discontinue aspirin therapy due to gastrointestinal side effects. No other adverse reactions to aspirin were noted.Aspirin desensitization following ESS appears to be a well-tolerated and effective adjunctive therapy for long-term control of nasal polyposis in patients with AERD.

    View details for DOI 10.1177/0194599814545750

    View details for Web of Science ID 000342982900008

  • Modification of the Lund-Kennedy Endoscopic Scoring System Improves Its Reliability and Correlation With Patient-Reported Outcome Measures LARYNGOSCOPE Psaltis, A. J., Li, G., Vaezeafshar, R., Cho, K., Hwang, P. H. 2014; 124 (10): 2216-2223

    View details for DOI 10.1002/lary.24654

    View details for Web of Science ID 000342749100007

  • Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence-based review and recommendations INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Gan, E. C., Thamboo, A., Rudmik, L., Hwang, P. H., Ferguson, B. J., Javer, A. R. 2014; 4 (9): 702-715


    Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence-based approach for the medical management of AFRS.A systemic review of the literature on the medical management of AFRS was performed using Medline, EMBASE, and Cochrane Review Databases up to March 15, 2013. The inclusion criteria were as follows: patients >18 years old; AFRS as defined by Bent and Kuhn; post-sinus surgery; studies with a clearly defined end point to evaluate the effectiveness of medical therapy in postoperative AFRS patients.This review identified and assessed 6 medical modalities for AFRS in the literature: oral steroids; topical steroids; oral antifungals; topical antifungals; immunotherapy; and leukotriene modulators.Based on available evidence in the literature, postoperative systemic and standard topical nasal steroids are recommended in the medical management of AFRS. Nonstandard topical nasal steroids, oral antifungals, and immunotherapy are options in cases of refractory AFRS. No recommendations can be provided for topical antifungals and leukotriene modulators due to insufficient clinical research reported in the literature.

    View details for DOI 10.1002/alr.21352

    View details for Web of Science ID 000341767900003

    View details for PubMedID 25044729

  • Frontal ostium neo-osteogenesis and patency after Draf III procedure: a computer-assisted study INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Ye, T., Hwang, P. H., Huang, Z., Huang, Q., Xian, J., Li, C., Zhou, B. 2014; 4 (9): 739-744


    Stenosis of the frontal neo-ostium after Draf III procedure has been associated with inflammatory risk factors. However, the degree to which neo-osteogenesis contributes to postsurgical stenosis of the frontal neo-ostium is unclear.Twenty-five patients with chronic frontal sinusitis who underwent Draf III procedure and had been followed for at least 12 months were included. Paranasal sinus computed tomography (CT) scans were performed 7 days and 1 year postoperatively. The frontal neo-ostium cross-sectional area and the amount of frontal neo-osteogenesis were measured by a standardized protocol using triplanar radiologic viewing software. Association between the severity of frontal neo-osteogenesis and the patency of the neo-ostium was analyzed, as was the correlation between the extent of neo-osteogenesis and the preoperative Global Osteitis Scoring Scale (GOSS), Lund-Mackay score (LMS), Lund-Kennedy score (LKS), serum eosinophil count, and history of previous surgery.At 1 year postoperatively, significant inverse correlation was found between the size of the frontal neo-ostium and the extent of neo-osteogenesis. According to a multiple linear regression model, the severity of neo-osteogenesis was positively correlated with preoperative GOSS and negatively correlated with asthma (p < 0.05). Additionally, there was no association between extent of neo-osteogenesis and the preoperative LMS, LKS, serum eosinophil count, and history of previous surgery.Neo-osteogenesis has a significant impact on the patency of the frontal neo-ostium but appears unrelated to inflammatory factors. Patients with a higher risk for developing neo-osteogenesis can be identified preoperatively based on GOSS; these patients may benefit from closer monitoring during the follow-up period.

    View details for DOI 10.1002/alr.21357

    View details for Web of Science ID 000341767900007

    View details for PubMedID 25079177

  • Productivity costs in patients with refractory chronic rhinosinusitis. Laryngoscope Rudmik, L., Smith, T. L., Schlosser, R. J., Hwang, P. H., Mace, J. C., Soler, Z. M. 2014; 124 (9): 2007-2012


    Disease-specific reductions in patient productivity can lead to substantial economic losses to society. The purpose of this study was to: 1) define the annual productivity cost for a patient with refractory chronic rhinosinusitis (CRS) and 2) evaluate the relationship between degree of productivity cost and CRS-specific characteristics.Prospective, multi-institutional, observational cohort study.The human capital approach was used to define productivity costs. Annual absenteeism, presenteeism, and lost leisure time was quantified to define annual lost productive time (LPT). LPT was monetized using the annual daily wage rates obtained from the 2012 U.S. National Census and the 2013 U.S. Department of Labor statistics.A total of 55 patients with refractory CRS were enrolled. The mean work days lost related to absenteeism and presenteeism were 24.6 and 38.8 days per year, respectively. A total of 21.2 household days were lost per year related to daily sinus care requirements. The overall annual productivity cost was $10,077.07 per patient with refractory CRS. Productivity costs increased with worsening disease-specific QoL (r?=?0.440; p?=?0.001).Results from this study have demonstrated that the annual productivity cost associated with refractory CRS is $10,077.07 per patient. This substantial cost to society provides a strong incentive to optimize current treatment protocols and continue evaluating novel clinical interventions to reduce this cost.N/A. Laryngoscope, 124:2007-2012, 2014.

    View details for DOI 10.1002/lary.24630

    View details for PubMedID 24619604

  • Update on evidence-based reviews with recommendations in adult chronic rhinosinusitis. International forum of allergy & rhinology Orlandi, R. R., Smith, T. L., Marple, B. F., Harvey, R. J., Hwang, P. H., Kern, R. C., Kingdom, T. T., Luong, A., Rudmik, L., Senior, B. A., Toskala, E., Kennedy, D. W. 2014; 4: S1-S15


    Chronic rhinosinusitis (CRS) has a significant impact not only on individuals who are afflicted but also on society as a whole. An increasing emphasis is being placed on incorporating the best available evidence into the care of patients, in association with an individual clinician's expertise and the patient's values. Recent evidence-based reviews with recommendations (EBRRs) have distilled our knowledge of CRS treatment options and have also pointed out continued gaps in this knowledge. This review synthesizes the findings of 8 EBRRs regarding CRS published in the International Forum of Allergy and Rhinology between 2011 and 2014. The recommendations in this review are based on the best available evidence and are meant to be incorporated into each patient's individual care, along with the practitioner's expertise and the individual patient's values and expectations. It is hoped that the EBRRs, and the process that spawned them, can provide the foundation for future guidelines in the diagnosis and management of CRS.

    View details for DOI 10.1002/alr.21344

    View details for PubMedID 24889751

  • Mucociliary clearance and submucosal gland secretion in the ex vivo ferret trachea. American journal of physiology. Lung cellular and molecular physiology Jeong, J. H., Joo, N. S., Hwang, P. H., Wine, J. J. 2014; 307 (1): L83-93


    In many species submucosal glands are an important source of tracheal mucus, but the extent to which mucociliary clearance (MCC) depends on gland secretion is unknown. To explore this relationship, we measured basal and agonist-stimulated MCC velocities in ex vivo tracheas from adult ferrets and compared the velocities with previously measured rates of ferret glandular mucus secretion (Cho HJ, Joo NS, Wine JJ. Am J Physiol Lung Cell Mol Physiol 299: L124-L136, 2010). Stimulated MCC velocities (mm/min, means ± SE for 10- to 35-min period poststimulation) were as follows: 1 ?M carbachol: 19.1 ± 3.3 > 10 ?M phenylephrine: 15.3 ± 2.4 ? 10 ?M isoproterenol: 15.0 ± 1.9 ? 10 ?M forskolin: 14.6 ± 3.1 > 1 ?M vasoactive intestinal peptide (VIP): 10.2 ± 2.2 > basal (t15): 1.8 ± 0.3; n = 5-10 for each condition. Synergistic stimulation of MCC was observed between low concentrations of carbachol (100 nM) and isoproterenol (300 nM). Bumetanide inhibited carbachol-stimulated MCC by ~70% and abolished the increase in MCC stimulated by forskolin + VIP, whereas HCO3 (-)-free solutions did not significantly inhibit MCC to either intracellular Ca(2+) concentration or intracellular cAMP concentration ([cAMP]i)-elevating agonists. Stimulation and inhibition of MCC and gland secretion differed in several respects: most importantly, elevating [cAMP]i increased MCC much more effectively than expected from its effects on gland secretion, and bumetanide almost completely inhibited [cAMP]i-stimulated MCC while it had a smaller effect on gland secretion. We conclude that changes in glandular fluid secretion are complexly related to MCC and discuss possible reasons for this.

    View details for DOI 10.1152/ajplung.00009.2014

    View details for PubMedID 24793168

  • Update on evidence-based reviews with recommendations in adult chronic rhinosinusitis. International forum of allergy & rhinology Orlandi, R. R., Smith, T. L., Marple, B. F., Harvey, R. J., Hwang, P. H., Kern, R. C., Kingdom, T. T., Luong, A., Rudmik, L., Senior, B. A., Toskala, E., Kennedy, D. W. 2014; 4: S1-S15

    View details for DOI 10.1002/alr.21344

    View details for PubMedID 24889751

  • Mucociliary clearance and submucosal gland secretion in the ex vivo ferret trachea AMERICAN JOURNAL OF PHYSIOLOGY-LUNG CELLULAR AND MOLECULAR PHYSIOLOGY Jeong, J. H., Joo, N. S., Hwang, P. H., Wine, J. J. 2014; 307 (1): L83-L93
  • Commentary on "How to avoid mucocele formation under pedicled nasoseptal flap". American journal of otolaryngology Vaezeafshar, R., Hwang, P. H., Turner, J. H. 2014; 35 (4): 547-?

    View details for DOI 10.1016/j.amjoto.2014.03.009

    View details for PubMedID 24815956

  • Outpatient endoscopic sinus surgery in cystic fibrosis patients: predictive factors for admission. International forum of allergy & rhinology Soudry, E., Mohabir, P. K., Miglani, A., Chen, J., Nayak, J. V., Hwang, P. H. 2014; 4 (5): 416-421


    An increasing number of adult patients with cystic fibrosis (CF) are becoming candidates for elective endoscopic sinus surgery (ESS). We sought to identify perioperative factors in this patient population that were predictive of postoperative admission.Retrospective chart review of CF patients who underwent ESS during the years 2005 through 2012. Multiple preoperative, intraoperative, and immediate postoperative variables were analyzed.Thirty-three patients who underwent 37 outpatient ESSs were identified. Successful same-day discharge was observed in 54%. In 46% of cases, postoperative admission was necessary, with a mean postoperative stay of 1.4 days. Pulmonary function, CF-related comorbidities, and history of lung transplant were not predictors of postoperative admission. Univariate analysis demonstrated that patients were more likely to be admitted if they had 1 of the following conditions: history of ?4 prior ESS; procedure duration >2.5 hours; intraoperative blood loss greater than 150 mL; increased immediate postoperative pain scores; or larger narcotic requirements for pain control. On logistic regression analysis, a maximum pain score ? 7 out of 10 in the postanesthesia recovery unit was the only significant predisposing factor for postoperative admission.Although over 50% of adult CF patients can successfully undergo ESS on a same-day discharge basis, it is prudent to have contingent plans for potential inpatient observation postoperatively. Multivariate analysis suggests that preoperative demographics and pulmonary status cannot predict the need for postoperative admission, whereas higher pain scores in the postanesthesia care unit are predictive of the necessity for inpatient observation.

    View details for DOI 10.1002/alr.21285

    View details for PubMedID 24431198

  • Outpatient endoscopic sinus surgery in cystic fibrosis patients: predictive factors for admission INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Soudry, E., Mohabir, P. K., Miglani, A., Chen, J., Nayak, J. V., Hwang, P. H. 2014; 4 (5): 416-421


    An increasing number of adult patients with cystic fibrosis (CF) are becoming candidates for elective endoscopic sinus surgery (ESS). We sought to identify perioperative factors in this patient population that were predictive of postoperative admission.Retrospective chart review of CF patients who underwent ESS during the years 2005 through 2012. Multiple preoperative, intraoperative, and immediate postoperative variables were analyzed.Thirty-three patients who underwent 37 outpatient ESSs were identified. Successful same-day discharge was observed in 54%. In 46% of cases, postoperative admission was necessary, with a mean postoperative stay of 1.4 days. Pulmonary function, CF-related comorbidities, and history of lung transplant were not predictors of postoperative admission. Univariate analysis demonstrated that patients were more likely to be admitted if they had 1 of the following conditions: history of ?4 prior ESS; procedure duration >2.5 hours; intraoperative blood loss greater than 150 mL; increased immediate postoperative pain scores; or larger narcotic requirements for pain control. On logistic regression analysis, a maximum pain score ? 7 out of 10 in the postanesthesia recovery unit was the only significant predisposing factor for postoperative admission.Although over 50% of adult CF patients can successfully undergo ESS on a same-day discharge basis, it is prudent to have contingent plans for potential inpatient observation postoperatively. Multivariate analysis suggests that preoperative demographics and pulmonary status cannot predict the need for postoperative admission, whereas higher pain scores in the postanesthesia care unit are predictive of the necessity for inpatient observation.

    View details for DOI 10.1002/alr.21285

    View details for Web of Science ID 000334895900013

    View details for PubMedID 24431198

  • Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Soudry, E., Turner, J. H., Nayak, J. V., Hwang, P. H. 2014; 150 (5): 730-738


    To systematically review the literature concerning techniques of closure of endoscopically created skull base defects based on site of skull base defect and flow rate of cerebrospinal fluid (CSF).PubMed, SCOPUS, and Cochrane databases.A comprehensive systematic literature review.The literature search produced a total of 1708 studies. Of these, 1585 studies were excluded based on title and/or abstract review. A total of 123 articles remained for full-text review, 101 of which were subsequently excluded primarily because of lack of detailed information as to the reconstructive techniques used or clinical outcomes. Of the 22 studies remaining for final analysis, all were case series. A total of 673 patients were included in the analysis, with an overall postoperative CSF leak rate of 8.5%. Subgroup analysis was performed based on location of the skull base defect and presence and quality of intraoperative CSF leak.Based on level 4 evidence, in cases of low-flow intraoperative CSF leaks, skull base reconstruction with multilayered free grafts and synthetic materials offers similar outcomes to vascularized flaps. In cases of high-flow intraoperative CSF leaks, pedicled vascularized flaps appear to be superior. Location of the defect does not seem to be a significant factor in determining successful closure, with the exception of clival defects. In all other sites, good closure may be achieved by multiple reconstructive approaches. More consistency in data reporting and higher levels of evidence will ultimately be necessary to make definitive recommendations.

    View details for DOI 10.1177/0194599814520685

    View details for PubMedID 24493791

  • Academic rhinology: a survey of residency programs and rhinology faculty in the United States. International forum of allergy & rhinology Tabaee, A., Chen, L., Smith, T. L., Hwang, P. H., Schaberg, M., Raithatha, R., Brown, S. M. 2014; 4 (4): 321-328


    Rhinology has rapidly evolved as a subspecialty over the past decade. The professional activities of rhinology faculty in otolaryngology residency programs is an important defining feature of this process but remains incompletely understood.An examination of faculty profiles of otolaryngology residency programs in the United States was performed to examine the professional activities of rhinologists. An anonymous, web-based survey of rhinology faculty was also performed to query professional activities and career satisfaction.Nine percent of chairmen and 12% of residency program directors were rhinologists. The number of full-time rhinology faculty members varied significantly among departments (mean 1; range, 0-4). Rhinology faculty members were noted to have a high number of scientific publications over the past 5 years (mean 15 per faculty), a high level of membership to the American Rhinologic Society (90%) and modest levels of membership to other societies. As reported by the 45 respondents who successfully completed the survey, higher percentages of professional time was devoted to clinical medicine when compared with administrative and research activities. Inflammatory sinusitis represented the most common clinical condition treated, and there was variability with respect to other disorders and procedures. Career satisfaction scores were highest for medical and surgical care, teaching activities, financial and emotional well being, and overall career to date. Lower satisfaction scores were noted for research and administrative activities and for balance of personal life with work.This study further defines the professional, clinical, and surgical activities of academic rhinologists. Continued analysis of the subspecialization of rhinology is required.

    View details for DOI 10.1002/alr.21268

    View details for PubMedID 24407909

  • Human ethmoid sinus mucosa: a promising novel tissue source of mesenchymal progenitor cells STEM CELL RESEARCH & THERAPY Cho, K., Park, H., Roh, H., Bravo, D. T., Hwang, P. H., Nayak, J. V. 2014; 5

    View details for DOI 10.1186/scrt404

    View details for Web of Science ID 000331727700003

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


    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

  • Nasal Microenvironments and Interspecific Interactions Influence Nasal Microbiota Complexity and S. aureus Carriage. Cell host & microbe Yan, M., Pamp, S. J., Fukuyama, J., Hwang, P. H., Cho, D., Holmes, S., Relman, D. A. 2013; 14 (6): 631-640


    The indigenous microbiota of the nasal cavity plays important roles in human health and disease. Patterns of spatial variation in microbiota composition may help explain Staphylococcus aureus colonization and reveal interspecies and species-host interactions. To assess the biogeography of the nasal microbiota, we sampled healthy subjects, representing both S. aureus carriers and noncarriers at three nasal sites (anterior naris, middle meatus, and sphenoethmoidal recess). Phylogenetic compositional and sparse linear discriminant analyses revealed communities that differed according to site epithelium type and S. aureus culture-based carriage status. Corynebacterium accolens and C. pseudodiphtheriticum were identified as the most important microbial community determinants of S. aureus carriage, and competitive interactions were only evident at sites with ciliated pseudostratified columnar epithelium. In vitro cocultivation experiments provided supporting evidence of interactions among these species. These results highlight spatial variation in nasal microbial communities and differences in community composition between S. aureus carriers and noncarriers.

    View details for DOI 10.1016/j.chom.2013.11.005

    View details for PubMedID 24331461

  • 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


    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 PubMedID 24124079

  • 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

    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


    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

  • 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

    View details for DOI 10.1002/alr.21221

    View details for PubMedID 24106221

  • 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


    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?

    View details for DOI 10.1002/lary.24027

    View details for Web of Science ID 000325091100005

    View details for PubMedID 23856802

  • 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

    View details for DOI 10.1002/alr.21205

    View details for PubMedID 23901007

  • 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


    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-?6 (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

  • 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


    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


    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

    View details for DOI 10.1002/alr.21133

    View details for PubMedID 23281318

  • 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


    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


    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


    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

    View details for DOI 10.2500/ajra.2013.27.3858

    View details for PubMedID 23562203

  • 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


    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


    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


    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


    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


    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-?


    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

    View details for PubMedCentralID PMC4161455

  • Interrater agreement of nasal endoscopy for chronic rhinosinusitis Annual Scientific Meeting of the American-Rhinologic-Society 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?50


    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

  • 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


    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


    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


    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


    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


    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


    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


    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

  • The effectiveness of preemptive sphenopalatine ganglion block on postoperative pain and functional outcomes after functional endoscopic sinus surgery 56th Annual Fall Scientific Meeting of the American-Rhinologic-Society (ARS) Cho, D., Drover, D. R., Nekhendzy, V., Butwick, A. J., Collins, J., Hwang, P. H. WILEY-BLACKWELL. 2011: 212?18


    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

  • 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


    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

  • Correlations Between Symptoms, Nasal Endoscopy, and In-Office Computed Tomography in Post-Surgical Chronic Rhinosinusitis Patients Conference on Triological-Society/Combined Otolaryngology Spring Meeting/143rd Annual Meeting of the American-Otological-Society Ryan, W. R., Ramachandra, T., Hwang, P. H. WILEY-BLACKWELL. 2011: 674?78


    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 Annual Spring Meeting of the American-Rhinologic-Society (ARS) / Combined Meeting of the Society-of-Otolaryngology / COSM Meeting Cho, D., Hwang, P. H., Illek, B., Fischer, H. WILEY-BLACKWELL. 2011: 123?27


    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

  • 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


    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


    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


    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


    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


    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


    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


    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

  • Determinants of outcomes of sinus surgery: A multi-institutional prospective cohort study 113th Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery-Foundation-and-OTO-EXPO 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


    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

  • Mechanistic Studies of Tolerance in sublingual innmunotherapy (SLIT) patients with Dermatophagoides farinae and Timothy grass allergy 10th Annual Meeting of the Federation-of-Clinical-Immunology-Societies 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
  • Controlled steroid delivery via bioabsorbable stent: Safety and performance in a rabbit model Spring Meeting of the American-Rhinologic-Society/Rhinology World Conference 2009 Li, P. F., Downie, D., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2009: 591?96


    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

  • Integration of patient-specific paranasal sinus computed tomographic data into a virtual surgical environment 54th Annual Fall Meeting of the American-Rhinologic-Society 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. OCEAN SIDE PUBLICATIONS INC. 2009: 442?47


    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


    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 54th Annual Fall Meeting of the American-Rhinologic-Society Cho, D., Hwang, P. H., Illek, B. OCEAN SIDE PUBLICATIONS INC. 2009: 294?99


    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


    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 Spring Meeting of the American-Rhinologic-Society/Combined Otolaryngology Spring Meeting Cho, D., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2008: 658?62


    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


    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


    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


    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

  • Radiographic assessment of the sinuses in patients treated for nasopharyngeal carcinoma AMERICAN JOURNAL OF RHINOLOGY Raviv, J., Downing, L., Le, Q., Hwang, P. 2008; 22 (1): 64-67


    Patients undergoing therapy for nasopharyngeal carcinoma (NPC) often experience dysfunction of the sinonasal mucosa as a side effect of radiotherapy and chemotherapy. Sinonasal mucosal changes may vary throughout the treatment and posttreatment periods, but little objective data exist characterizing such changes. We evaluated serial radiologic changes of the paranasal sinus mucosa in patients with NPC undergoing treatment.Medical and radiographic records were reviewed for all patients treated for NPC between 2004 and 2006 at Stanford University Medical Center. Pretreatment computed tomography (CT) images served as the baseline images for comparison, and posttreatment CT and magnetic resonance imaging (MRI) images were categorized temporally into 3-month intervals, up to 25 months after initiation of treatment. Images were scored in a blinded fashion using the Lund-Mackay (LM) staging system.Thirty-five patients received treatment for NPC during the study period, of whom 27 had adequate data for analysis and inclusion in the study. The mean pretreatment LM score was 1.41, and a statistically significant increase in LM score was observed at 3, 6, 9, 12, 15, and 18, 22, and 28 months. There was continued progression of radiologic sinus opacification over the first 30 months after treatment.The treatment of NPC with radiotherapy and chemotherapy is associated with radiologic evidence of sinus mucosal thickening. The extent of mucosal thickening can be expected to progress after treatment for up to 30 months. Patients undergoing treatment for NPC should be monitored carefully throughout the posttreatment period for clinical manifestations of dysfunctional sinonasal mucosa.

    View details for DOI 10.2500/ajr.2007.21.3091

    View details for Web of Science ID 000253232100012

    View details for PubMedID 17958946

  • 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


    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 52nd Annual Meeting of the American-Rhinologic-Society Leung, M., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2007: 271?75


    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


    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


    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


    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


    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-?


    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 109th Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery-Foundation Ghaheri, B. A., Fong, K. J., Hwang, P. H. MOSBY-ELSEVIER. 2006: 1006?9


    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 50th Annual Meeting of the American-Rhinologic-Society Hwang, P. H., Woo, R. J., Fong, K. J. OCEAN SIDE PUBLICATIONS INC. 2006: 255?61


    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


    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 Annual Meeting of the American-Rhinologic-Society Han, J. K., Smith, T. L., Loehrl, T. A., Fong, K. J., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2005: 478?82


    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 49th Annual Fall Meeting of the American-Rhinologic-Society Hwang, P. H., Han, J. K., Bilstrom, E. J., Kingdom, T. T., Fong, K. J. OCEAN SIDE PUBLICATIONS INC. 2005: 425?29


    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


    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-?


    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-?


    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-?


    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 Meeting of the Western-Section of the Triological-Society Shiley, S. G., Limonadi, F., Delashaw, J. B., Barnwell, S. L., Andersen, P. E., Hwang, P. H., Wax, M. K. JOHN WILEY & SONS INC. 2003: 1283?88


    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


    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


    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


    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


    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 Annual Meeting of the Western-Section of the Triological-Society Gross, N. D., McInnes, R. J., Hwang, P. H. JOHN WILEY & SONS INC. 2002: 1758?61


    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


    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

  • Bony abnormalities of the paranasal sinuses in patients with Wegener's granulomatosis Annual Meeting of the American-Rhinologic-Society Yang, C., Talbot, J. M., Hwang, P. H. OCEAN SIDE PUBLICATIONS INC. 2001: 121?25


    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

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


    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-?


    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


    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


    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

  • Endoscopic septoplasty: Indications, technique, and results 101st Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Hwang, P. H., McLaughlin, R. B., Lanza, D. C., Kennedy, D. W. MOSBY-ELSEVIER. 1999: 678?82


    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

  • 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-Rhinologic-Society Meeting, Combined Otolaryngological Spring Meeting Hwang, P. H., Maas, C. S. OCEAN SIDE PUBLICATIONS INC. 1998: 213?20


    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 100th Annual Meeting of the American-Laryngological-Rhinological-and-Otological-Society Kennedy, D. W., Senior, B. A., Gannon, F. H., Montone, K. T., Hwang, P., Lanza, D. C. JOHN WILEY & SONS INC. 1998: 502?7


    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


    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

  • Attitudes, knowledge, and practices of otolaryngologists treating patients infected with HIV Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Hwang, P. H., Tami, T. A., Lee, K. C., Raven, R. B. MOSBY-YEAR BOOK INC. 1995: 733?39


    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 (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

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

    View details for PubMedID 10149522



    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

Footer Links:

Stanford Medicine Resources: