Zara M. Patel

All Publications

• Enhanced Tearing by Electrical Stimulation of the Anterior Ethmoid Nerve INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Brinton, M., Kossler, A. L., Patel, Z. M., Loudin, J., Franke, M., Ta, C. N., Palanker, D. 2017; 58 (4): 2341-2348

  Abstract

  Electrical neurostimulation enhances tear secretion, and can be applied to treatment of dry eye disease. Using a chronic implant, we evaluate the effects of stimulating the anterior ethmoid nerve on the aqueous, lipid, and protein content of secreted tears.Neurostimulators were implanted beneath the nasal mucosa in 13 New Zealand white rabbits. Stimulations (2.3-2.8 mA pulses of 75-875 μs in duration repeated at 30-100 Hz for 3 minutes) were performed daily, for 3 weeks to measure changes in tear volume (Schirmer test), osmolarity (TearLab osmometer), lipid (Oil-Red-O staining), and protein (BCA assay, mass spectrometry).Stimulation of the anterior ethmoid nerve in the frequency range of 30 to 90 Hz increased tear volume by 92% to 133% (P ≤ 0.01). Modulating the treatment with 50% duty cycle (3 seconds of stimulation repeated every 6 seconds) increased tear secretion an additional 23% above continuous stimulation (P ≤ 0.01). Tear secretion returned to baseline levels within 7 minutes after stimulation ended. Tear film osmolarity decreased by 7 mOsmol/L, tear lipid increased by 24% to 36% and protein concentration increased by 48% (P ≤ 0.05). Relative abundance of the lacrimal gland proteins remained the same, while several serum and corneal proteins decreased with stimulation (P ≤ 0.05).Electrical stimulation of the anterior ethmoid nerve increased aqueous tear volume, reduced tear osmolarity, added lipid, and increased the concentration of normal tear proteins. Human studies with an intranasal stimulator should verify these effects in patients with aqueous- and lipid-deficient forms of dry eye disease.

  View details for DOI 10.1167/iovs.16-21362

  View details for Web of Science ID 000400649600047

  View details for PubMedID 28431436

  View details for PubMedCentralID PMC5398789

• 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

  Abstract

  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

• Office Procedures in Refractory Chronic Rhinosinusitis OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Thamboo, A., Patel, Z. M. 2017; 50 (1): 113-?

  Abstract

  Office procedures in chronic rhinosinusitis (CRS) can be considered before and after medical management, as well as before and after surgical management. This article focuses specifically on refractory CRS, meaning those patients who have failed medical and surgical management already. The options available in the management of refractory CRS depend on the personnel, equipment, and instrumentation available in the office setting; surgeon experience; and patient suitability and tolerability. This article provides readers with possible procedural options that can be done in their clinics with indications, patient selection, potential complications, and postoperative considerations.

  View details for DOI 10.1016/j.otc.2016.08.010

  View details for Web of Science ID 000390983700010

  View details for PubMedID 27888908

• The evidence for olfactory training in treating patients with olfactory loss CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Patel, Z. M. 2017; 25 (1): 43-46

  Abstract

  The purpose of this review is to go over the only therapy for olfactory loss supported by level 1a evidence that is currently available, which is olfactory training. This therapy is widely underutilized and has the potential to help many patients with olfactory dysfunction who are otherwise offered no management options.We will review the rationale, clinical studies, and quality of the evidence regarding olfactory training, specifically the olfactory system's inherent ability to regenerate, the plasticity of the system, and the multiple protocols and modifications of protocols present in the literature.Olfactory training is an effective therapy for some patients suffering from olfactory loss, and, while we do not yet know the optimal duration or number of odorants or exact patient population it may be most beneficial for, as an extremely easy, self-driven therapy with no significant side-effects, it should be consistently offered to this patient population.

  View details for DOI 10.1097/MOO.0000000000000328

  View details for Web of Science ID 000392100000009

  View details for PubMedID 27841770

• Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Shahangian, A., Soler, Z. M., Baker, A., Wise, S. K., Rereddy, S. K., Patel, Z. M., Oyesiku, N. M., DelGaudio, J. M., Hadjipanayis, C. G., Woodworth, B. A., Riley, K. O., Lee, J., Cusimano, M. D., Govindaraj, S., Khan, M. N., Psaltis, A., Wormald, P. J., Santoreneos, S., Sindwani, R., Trosman, S., Stokken, J. K., Woodard, T. D., Recinos, P. F., Vandergrift, W. A., Boling, C., Schlosser, R. J. 2017; 7 (1): 80-86

  Abstract

  The impact of failed cerebrospinal fluid leak (CSF) leak repair in endoscopic skull base surgery has not been adequately studied.In this investigation we reviewed patients who had undergone endoscopic skull base surgery between 2002 and 2014 at 7 international centers. Demographic variables, comorbidities, tumor characteristics, and repair techniques were evaluated to determine association with successful repair of CSF leak. Postoperative complications and length of stay were compared among groups.Data were collected on 2097 patients who were divided into 3 groups: (1) those with no intraoperative leak (n = 1533); (2) those with successful repair of their intraoperative leak (n = 452); and (3) those with failed repair (n = 112). Compared with successful repair, failed repair was associated with an increased risk of intracranial infection (odds ratio [OR], 5.6; 95% confidence interval [CI], 5.3-13.15), pneumocephalus (OR, 16; 95% CI, 5.8-44.4), 30-day readmission (OR, 8.4; 95% CI, 5.3-13.5), reoperation (OR, 115.4; 95% CI, 56.3-236.8), and prolonged hospital stay (14.9 vs 7.0 days, p < 0.01). Outcomes in patients who had successful repairs of intraoperative leaks were similar to those who never had leakage. Intraoperative use of pedicled nasoseptal flaps was associated with successful repair (OR, 0.60; 95% CI, 0.34-0.92).Intraoperative CSF leaks are a frequent and expected occurrence during endoscopic skull base surgery. Failed CSF leak repair has a significant impact on patient outcomes, with increased rates of postoperative pneumocephalus, intracranial infections, reoperation, deep vein thrombosis, readmission, and prolonged hospital stay. Recognition and repair of intraoperative CSF leaks reduces postoperative complications. Use of pedicled nasoseptal flaps improves outcomes in reconstructing defects at higher risk for postoperative leak.

  View details for DOI 10.1002/alr.21845

  View details for Web of Science ID 000394900500012

  View details for PubMedID 27579523

• 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

  Abstract

  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 (Δ = 24.1; Δ = 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

  Abstract

  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 (ρ) 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 (ρ = 0.691, p < 0.001). The correlation coefficient between ETDQ-7 and total SNOT-22 scores was ρ = 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 (ρ = -0.055, p = 0.594) and Lund-Kennedy endoscopy score (ρ = -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

• Randomized Controlled Trial Demonstrating Cost-Effective Method of Olfactory Training in Clinical Practice Laryngoscope Investigative Otolaryngology Patel, Z. M., Wise, S. K., DelGaudio, J. M. 2017

  View details for DOI 10.1002/lio2.62

• 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

  Abstract

  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

• Barosinusitis: Comprehensive review and proposed new classification system. Allergy & rhinology (Providence, R.I.) Vaezeafshar, R., Psaltis, A. J., Rao, V. K., Zarabanda, D., Patel, Z. M., Nayak, J. V. 2017; 8 (3): 109–17

  Abstract

  Barosinusitis, or sinus barotrauma, may arise from changes in ambient pressure that are not compensated by force equalization mechanisms within the paranasal sinuses. Barosinusitis is most commonly seen with barometric changes during flight or diving. Understanding and better classifying the pathophysiology, clinical presentation, and management of barosinusitis are essential to improve patient care.To perform a comprehensive review of the available literature regarding sinus barotrauma.A comprehensive literature search that used the terms "barosinusitis," "sinus barotrauma," and "aerosinusitis" was conducted, and all identified titles were reviewed for relevance to the upper airway and paranasal sinuses. All case reports, series, and review articles that were identified from this search were included. Selected cases of sinus barotrauma from our institution were included to illustrate classic signs and symptoms.Fifty-one articles were identified as specifically relevant to, or referencing, barosinusitis and were incorporated into this review. The majority of articles focused on barosinusitis in the context of a single specific etiology rather than independent of etiology. From analysis of all the publications combined with clinical experience, we proposed that barosinusitis seemed to fall within three distinct subtypes: (1) acute, isolated barosinusitis; (2) recurrent acute barosinusitis; and (3) chronic barosinusitis. We introduced this terminology and suggested independent treatment recommendations for each subtype.Barosinusitis is a common but potentially overlooked condition that is primed by shifts in the ambient pressure within the paranasal sinuses. The pathophysiology of barosinusitis has disparate causes, which likely contribute to its misdiagnosis and underdiagnosis. Available literature compelled our proposed modifications to existing classification schemes, which may allow for improved awareness and management strategies for barosinusitis.

  View details for DOI 10.2500/ar.2017.8.0221

  View details for PubMedID 29070267

  View details for PubMedCentralID PMC5662535

• Variables associated with olfactory disorders in adults: A U.S. population-based analysis. World journal of otorhinolaryngology - head and neck surgery Noel, J., Habib, A. R., Thamboo, A., Patel, Z. M. 2017; 3 (1): 9–16

  Abstract

  Olfactory dysfunction is known to have significant social, psychological, and safety implications. Despite increasingly recognized prevalence, potential risk factors for olfactory loss have been arbitrarily documented and knowledge is limited in scale. The aim of this study is to identify potential demographic and exposure variables correlating with olfactory dysfunction.Cross-sectional analysis of the 2011-2012 and 2013-2014 editions of the National Health Examination and Nutrition Survey was performed. The utilized survey reports from a nationally representative sample of about 5000 persons each year located in counties across the United States. There is an interview and physical examination component which includes demographic, socioeconomic, dietary, and health-related questions as well as medical, dental, physiologic measurements, and laboratory tests. 3594 adult respondents from 2011 to 2012 and 3708 respondents from 2013 to 2014 were identified from the above population-based database. The frequency of self-reported disorders as well as performance on odor identification testing was determined in relation to demographic factors, occupational or environmental exposures, and urinary levels of environmental and industrial compounds.In both subjective and objective analysis, smell disorders were significantly more common with increasing age. While the non-Hispanic Black and non-Hispanic Asian populations were less likely to report subjective olfactory loss, they, along with Hispanics, performed more poorly on odor identification than Caucasians. Those with limited education had a decreased prevalence of hyposmia. Women outperformed men on smell testing. Those reporting exposure to vapors were more likely to experience olfactory dysfunction, and urinary levels of manganese, 2-Thioxothiazolidine-4-carboxylic acid, and 2-Aminothiazoline-4-carboxylic acid were lower among respondents with subjective smell disturbance. In odor detection, elevated serum levels of lead and urinary levels of 2,4 dichlorophenol were associated with anosmia and hyposmia, respectively.This study provides current, population-based data identifying demographic and exposure elements related to smell disturbances in U.S. adults. Age, race, gender, education, exposure to vapors, urinary levels of manganese, 2-Thioxothiazolidine-4-carboxylic acid, 2-Aminothiazoline-4-carboxylic acid, 2,4 dichlorophenol, and serum lead levels were all implicated in smell disturbance. Care should be taken in interpretation due to lack of consistency between subjective and objective measures of olfaction as well as limitations related to population-based data. Prospective trials are indicated to further elucidate these relationships.

  View details for DOI 10.1016/j.wjorl.2017.02.005

  View details for PubMedID 29204574

  View details for PubMedCentralID PMC5683598

• Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery. International forum of allergy & rhinology Karnezis, T. T., Baker, A. B., Soler, Z. M., Wise, S. K., Rereddy, S. K., Patel, Z. M., Oyesiku, N. M., DelGaudio, J. M., Hadjipanayis, C. G., Woodworth, B. A., Riley, K. O., Lee, J., Cusimano, M. D., Govindaraj, S., Psaltis, A., Wormald, P. J., Santoreneos, S., Sindwani, R., Trosman, S., Stokken, J. K., Woodard, T. D., Recinos, P. F., Vandergrift, W. A., Schlosser, R. J. 2016; 6 (11): 1117-1125

  Abstract

  In patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information.A retrospective review of patients undergoing endoscopic sellar surgery for pituitary adenomas or craniopharyngiomas between 2002 and 2014 at 7 international centers was performed. Demographic, comorbidity, and tumor characteristics were evaluated to determine the associations between intraoperative and postoperative CSF leaks. Correlations between reconstructive and CSF diversion techniques were associated with postoperative CSF leak rates. Odds ratios (OR) were identified using a multivariate logistic regression model.Data were collected on 1108 pituitary adenomas and 53 craniopharyngiomas. Overall, 30.1% of patients had an intraoperative leak and 5.9% had a postoperative leak. Preoperative factors associated with increased intraoperative leaks were mild liver disease, craniopharyngioma, and extension into the anterior cranial fossa. In patients with intraoperative CSF leaks, postoperative leaks occurred in 10.3%, with a higher postoperative leak rate in craniopharyngiomas (20.8% vs 5.1% in pituitary adenomas). Once an intraoperative leak occurred, craniopharyngioma (OR = 4.255, p = 0.010) and higher body mass index (BMI) predicted postoperative leak (OR = 1.055, p = 0.010). In patients with an intraoperative leak, the use of septal flaps reduced the occurrence of postoperative leak (OR = 0.431, p = 0.027). Rigid reconstruction and CSF diversion techniques did not impact postoperative leak rates.Intraoperative CSF leaks can occur during endoscopic sellar surgery, especially in larger tumors or craniopharyngiomas. Once an intraoperative leak occurs, risk factors for postoperative leaks include craniopharyngiomas and higher BMI. Use of septal flaps decreases this risk.

  View details for DOI 10.1002/alr.21783

  View details for PubMedID 27552303

• Determinants of racial differences in survival for sinonasal cancer. Laryngoscope Patel, Z. M., Li, J., Chen, A. Y., Ward, K. C. 2016; 126 (9): 2022-2028

  Abstract

  Racial differences in survival are present across multiple cancer types, including sinonasal cancer. Thus far in the literature, reasons for this have been theorized but not proven. We aimed to examine proposed potential factors and understand the true determinants in racial differences for survival in sinonasal cancer.Utilizing the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2000-2008), we analyzed multiple demographic, tumor-related, and treatment-related factors. Use of the Medicare subset allows much deeper examination of patient and treatment factors than the usual SEER database study.Univariate analysis and multivariate Cox proportional hazard regression models were used.Eight hundred and forty-five patients remained after exclusion criteria. Five-year cause-specific survival (CSS) was 62%, with a racial difference confirmed because non-Hispanic whites (NHW) and blacks and Hispanic whites (B/HW) demonstrated 64% and 52% CSS, respectively. After multivariate analysis, factors significantly determining racial survival were age, stage, histology, grade, comorbidity status, and standard of care.This study confirms the difference in racial survival in sinonasal cancer. In opposition to popular theories of access to care and education level- and poverty level-determining outcomes, those factors were not significant on multivariate analysis, whereas stage and receiving standard of care, determined by unimodality versus multimodality treatment appropriate to stage, were the two most important prognostic factors.2c. Laryngoscope, 126:2022-2028, 2016.

  View details for DOI 10.1002/lary.25897

  View details for PubMedID 26915596

• Immunotherapy compliance: comparison of subcutaneous versus sublingual immunotherapy INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Leader, B. A., Rotella, M., Stillman, L., DelGaudio, J. M., Patel, Z. M., Wise, S. K. 2016; 6 (5): 460-464

  Abstract

  Patient compliance is critical for successful allergen immunotherapy (AIT). Previous studies suggest that AIT compliance is worse outside of controlled clinical trials, with reported subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) noncompliance at 11% to 50% and 3% to 25%, respectively.A retrospective review of 384 AIT patients at a single, tertiary care otolaryngic allergy practice evaluated SCIT and SLIT compliance, based on treatment stage. SCIT compliance was defined as the number of 2-week breaks per year or in compliance with their defined schedule: excellent = 2 or fewer; good = 3 to 4; fair = 5 to 6; and poor = 7 or more. Compliance with SLIT was defined as the number of days vials were refilled within the defined expiration date: excellent = 10 days or fewer; good = 11 to 15 days, fair = 16 to 20 days; and poor = 25 or more days. Fisher exact and chi square tests were used for statistical analysis.Seventy-four SCIT and 200 SLIT patients had data appropriate for analysis. Compliance rates were excellent (62%) or good (22%) in 62 SCIT patients and excellent (31%) or good (35%) in 131 SLIT patients. Comparing excellent compliance rates, SCIT patients had a higher rate of excellent compliance at all stages of treatment compared to SLIT patients (p < 0.05). For SCIT patients there was no significant difference in excellent compliance rates between escalation, first year of maintenance, and greater than 1 year of maintenance (p > 0.05).The results of this study showed higher rates of patient adherence to treatment protocols among SCIT patients. There was no decrease in SCIT compliance rates across treatment stages.

  View details for DOI 10.1002/alr.21699

  View details for Web of Science ID 000375917100003

  View details for PubMedID 26718480

• Olfaction following endoscopic skull base surgery CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Patel, Z. M., DelGaudio, J. M. 2016; 24 (1): 70-74

  View details for DOI 10.1097/MOO.0000000000000216

  View details for Web of Science ID 000367599300013

• Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Boling, C. C., Karnezis, T. T., Baker, A. B., Lawrence, L. A., Soler, Z. M., Vandergrift, W. A., Wise, S. K., DelGaudio, J. M., Patel, Z. M., Rereddy, S. K., Lee, J. M., Khan, M. N., Govindaraj, S., Chan, C., Oue, S., Psaltis, A. J., Wormald, P., Trosman, S., Stokken, J., Woodard, T., Sindwani, R., Schlosser, R. J. 2016; 6 (1): 101-107

  Abstract

  The goal of this study was to identify preoperative risk factors associated with increased perioperative morbidity after endoscopic pituitary surgery.A retrospective review of patients undergoing endoscopic pituitary adenoma surgery between 2002 and 2014 at 6 international centers was performed. Standard demographic and comorbidity data, as well as information regarding tumor extent and treatment were collected. Logistic regression was used to examine risk factors for the following 30-day outcomes: systemic complications, intracranial complications, postoperative cerebrospinal fluid (CSF) leaks, length of hospital stay, readmission, and reoperation.Data was collected on 982 patients with a mean age of 52 years. The median body mass index (BMI) for all patients was 30.9 kg/m(2) with 56% female. The median hospital stay was 5 days and 23.8% of patients suffered a postoperative adverse event. Systemic complications occurred in 3.2% of patients and intraventricular extension was a risk factor (odds ratio [OR] 8.9). Intracranial complications occurred in 7.3% of patients and risk factors included previous radiation (OR 8.6) and intraventricular extension (OR 7.9). Reoperation occurred in 6.5% of patients and intraventricular extension (OR 7.3) and age (<40 years, OR 3.5; 40 to 64 years, OR 3.2) were risk factors. Postoperative CSF leaks occurred in 5.5% of patients and risk factors included female gender (OR 2.4), BMI ≥ 30 (OR 2.1), age (<40 years, OR 5.3; 40 to 64 years, OR, 7.9), and intraventricular extension (OR, 9.5).Postoperative endoscopic pituitary adenoma surgery complications are associated with tumors with intraventricular extension, preoperative radiation, as well as common patient comorbidities. Identification of these factors may permit implementation of strategies to reduce postoperative complications.

  View details for DOI 10.1002/alr.21622

  View details for Web of Science ID 000368007900015

  View details for PubMedID 26250607

• Management of non-invasive rhinosinusitis in the immunosuppressed patient population LARYNGOSCOPE Dao, A. M., Rereddy, S. K., Wise, S. K., DelGaudio, J. M., Patel, Z. M. 2015; 125 (8): 1767-1771

  Abstract

  Rhinologists are seeing an increasing number of immunosuppressed patients. Currently, no treatment paradigm exists for treating acute and chronic noninvasive rhinosinusitis (ARS, CRS) in this growing population. This study aims to identify patient and treatment factors that affect rhinosinusitis outcomes in this vulnerable population.Prognostic retrospective cohort study.Immunocompromised patients treated by rhinologists for ARS or CRS 10/2007 to 10/2012 were identified by rhinosinusitis diagnostic codes, codes for transplant, cancer, HIV, diabetes, and codes indicating immunosuppression in the intensive care setting. Associations between patient factors and outcome were analyzed by logistic regression. Associations between treatment and outcome were analyzed by Firth logistic regression.A total of 132 subjects were identified. Of those, 90.9% had CRS and 9.1% had ARS; 12.9% were transplant patients; 47% were diabetic; 37.9% were cancer patients; and 16.7% were in the intensive care unit. Patients with higher American Society of Anesthesiologists (ASA) scores had decreased disease resolution (odds ratio [OR] = 0.5, P = 0.021). Transplant patients (OR = 22.5, P = 0.001), diabetics patients (OR = 6.4, P = 0.017), cancer patients (OR = 5.4, P = 0.046), and patients with prior medical therapy for rhinosinusitis (OR = 5.84, P < 0.001) had increased disease resolution compared to immunosuppressed critical care patients. Patients treated with antibiotics alone had no statistically significant difference in disease resolution compared to those receiving no treatment. In contrast, treatment plans including surgery were associated with greater disease resolution.This data indicates that surgical treatment provides improved outcomes for patients presenting with acute exacerbations of rhinosinusitis related to their immunocompromised state. Given the limited study population, these findings may not apply to HIV-positive or ARS patients, and further study should be undertaken in these groups.4.

  View details for DOI 10.1002/lary.25305

  View details for Web of Science ID 000358379700012

  View details for PubMedID 25946593

• Clinical Practice Guideline (Update): Adult Sinusitis OTOLARYNGOLOGY-HEAD AND NECK SURGERY Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Kumar, K. A., Kramper, M., Orlandi, R. R., Palmer, J. N., Patel, Z. M., Peters, A., Walsh, S. A., Corrigan, M. D. 2015; 152: S1-S39

  Abstract

  This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

  View details for DOI 10.1177/0194599815572097

  View details for Web of Science ID 000352577900001

  View details for PubMedID 25832968

• Clinical Practice Guideline (Update): Adult Sinusitis Executive Summary OTOLARYNGOLOGY-HEAD AND NECK SURGERY Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Kumar, K. A., Kramper, M., Orlandi, R. R., Palmer, J. N., Patel, Z. M., Peters, A., Walsh, S. A., Corrigan, M. D. 2015; 152 (4): 598-609

  Abstract

  The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue featuring the updated "Clinical Practice Guideline: Adult Sinusitis" as a supplement to Otolaryngology-Head and Neck Surgery. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 developed recommendations address diagnostic accuracy for adult rhinosinusitis, the appropriate use of ancillary tests to confirm diagnosis and guide management (including radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function), and the judicious use of systemic and topical therapy. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. An updated guideline is needed as a result of new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

  View details for DOI 10.1177/0194599815574247

  View details for Web of Science ID 000352580000011

  View details for PubMedID 25833927

• Magnetic resonance cisternogram with intrathecal gadolinium with delayed imaging for difficult to diagnose cerebrospinal fluid leaks of anterior skull base INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY DelGaudio, J. M., Baugnon, K. L., Wise, S. K., Patel, Z. M., Aiken, A. H., Hudgins, P. A. 2015; 5 (4): 333-338

  Abstract

  Workup of cerebrospinal fluid (CSF) leaks can be challenging. Patients with intermittent or infrequent clear rhinorrhea that cannot be collected, those with questionable or multiple skull-base (SB) defects on imaging, and those with previous SB surgery can present diagnostic dilemmas. In this patient population, radiologic studies that allow repeat imaging over hours to days can increase the diagnostic yield. We report our experience with magnetic resonance cisternogram with intrathecal gadolinium (MRCgGd) in this patient population.This study was a retrospective review of patients who underwent MRCgGd for workup of suspected CSF leaks at a tertiary care academic center.Over the past 3 years, 11 patients (10 females; mean age 50 years) underwent MRCgGd. Seven patients had suspected spontaneous CSF leaks from idiopathic intracranial hypertension and 2 had postsurgical defects. All patients had previous imaging that was indeterminate in localizing the site of the leak. Only 3 patients had positive beta-2 transferrin studies, all with multiple potential leak sites. MRCgGd confirmed the absence of leaks at 4 previously repaired SB defects, identified spinal canal leaks but no SB leaks in 2 patients (1 of whom had a nonleaking SB defect), and identified 5 patients with one or more SB leaks. Repeat imaging, from 30 minutes to 20 hours, was beneficial in identifying 4 leaks not confirmed in the immediate imaging, and ruling out leaks in 5 cases, therefore guiding further treatment. No complications occurred.MRCgGd is a useful diagnostic test in the workup of patients with difficult CSF leaks, with delayed imaging providing valuable diagnostic information.

  View details for DOI 10.1002/alr.21475

  View details for Web of Science ID 000352580700012

  View details for PubMedID 25561376

• Association of Decreased Rate of Influenza Vaccination With Increased Subjective Olfactory Dysfunction JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY Flanagan, C. E., Wise, S. K., DelGaudio, J. M., Patel, Z. M. 2015; 141 (3): 225-228

  Abstract

  Seasonal influenza causes significant morbidity and mortality, with cardiovascular and respiratory complications the most common among susceptible individuals. Upper respiratory tract infections (URIs) are known to precede olfactory dysfunction in some patients. To our knowledge, there has been no study assessing the possible relationship between influenza vaccination status and olfactory dysfunction.To compare vaccination status of a group of patients with subjective olfactory dysfunction with that of a group of controls.Retrospective medical record review and telephone survey in a matched case-control study. Forty-two patients were identified via diagnosis codes who presented to a tertiary care academic rhinologic center with subjective smell dysfunction over the course of 1 year. Only post-URI and idiopathic etiologies were included. Forty-two age-, sex-, and race/ethnicity-matched control patients were also selected.Demographic data, influenza vaccination status, and smoking status were reviewed. χ² Testing was used.We were able to obtain vaccination data for 36 of 42 patients in the olfactory dysfunction group and 38 of 42 in the control group. Seven of the 36 (19%) in the olfactory dysfunction group had received the vaccine in the year prior to presentation compared with 16 of 38 (42%) in the control group (P = .04).Influenza vaccination seems to be associated with a decreased rate of subjective olfactory dysfunction. This is a preliminary finding, and further studies would be needed to elucidate the exact role of influenza and influenza vaccination in patients with olfactory loss.

  View details for DOI 10.1001/jamaoto.2014.3399

  View details for Web of Science ID 000351585000006

  View details for PubMedID 25590362

• Higher Body Mass Index Is Associated with Subjective Olfactory Dysfunction BEHAVIOURAL NEUROLOGY Patel, Z. M., DelGaudio, J. M., Wise, S. K. 2015

  Abstract

  Morbidly obese patients demonstrate altered olfactory acuity. There has been no study directly assessing Body Mass Index (BMI) in patients with olfactory dysfunction. Our purpose was to compare BMI in a group of patients with subjective olfactory dysfunction to those without subjective olfactory complaints.Retrospective matched case-control study. Sixty patients who presented to a tertiary care otolaryngology center with subjective smell dysfunction over one year were identified. Neoplastic and obstructive etiologies were excluded. Demographics, BMI, and smoking status were reviewed. Sixty age, gender, and race matched control patients were selected for comparison. Chi-square testing was used.48 out of 60 patients (80%) in the olfactory dysfunction group fell into the overweight or obese categories, compared to 36 out of 60 patients (60%) in the control group. There was a statistically significant difference between the olfactory dysfunction and control groups for this stratified BMI (p = 0.0168).  This study suggests high BMI is associated with olfactory dysfunction. Prospective clinical research should examine this further to determine if increasing BMI may be a risk factor in olfactory loss and to elucidate what role olfactory loss may play in diet and feeding habits of obese patients.

  View details for DOI 10.1155/2015/675635

  View details for Web of Science ID 000357531900001

  View details for PubMedID 26199458

• Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery. International Forum of Allergy and Rhinology Boling, C. 2015
• Endoscopic transsphenoidal pituitary surgery: transsphenoidal approach to the sella and sellar closure with septal flap: 3-dimensional operative video. Neurosurgery Chu, J., Wise, S. K., Patel, Z. M., Oyesiku, N. M. 2014; 10: 654-?

  View details for DOI 10.1227/NEU.0000000000000469

  View details for PubMedID 25409331

• The nasal floor pedicled flap: a novel technique for use in skull base reconstruction INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Daraei, P., Oyesiku, N. M., Patel, Z. M. 2014; 4 (11): 937-943

  Abstract

  Skull base reconstruction can be accomplished using various donor sites. Vascularized tissue, commonly the nasoseptal flap, is the most effective option for large defects or high flow leaks. In cases where the septum cannot be used, a mucoperiosteal flap from the nasal floor, pedicled from the sphenopalatine artery, is a viable option without reported outcomes. The aim of this work was to describe this flap and to report successful outcomes in a cohort of patients.Retrospective chart review of patients seen by the senior author from 2011 to 2013 requiring skull base reconstruction for defects with cerebrospinal fluid leak.A total of 108 patients underwent endoscopic skull base reconstruction. Ten patients had reconstruction with use of a pedicled nasal floor flap. Mean age was 53.3 years. Defects involved the ethmoid roof in 5 patients, sellar floor in 2, clivus in 2, and planum sphenoidale in 1. Reasons why the septal flap could not be used were intentional sacrifice due to disease involvement, sacrifice for proper exposure, or previous septal perforation. Mean length of follow-up was 10.2 (range, 4 to 25) months. No patient developed cerebrospinal fluid leaks postoperatively.Nasal floor pedicled flaps are an effective alternative to nasoseptal flaps for reconstruction of the skull base, and have not been previously described in the literature. Outcomes are promising in our small cohort of patients. If the septum must be sacrificed, attention should be paid to the nasal floor, which provides a large mucoperiosteal flap that can be consistently exposed and elevated by the experienced surgeon.

  View details for DOI 10.1002/alr.21369

  View details for Web of Science ID 000344361600013

  View details for PubMedID 25224141

• Evaluation and Management of "Sinus Headache" in the Otolaryngology Practice OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Patel, Z. M., Setzen, M., Poetker, D. M., DelGaudio, J. M. 2014; 47 (2): 269-?

  Abstract

  Patients, primary care doctors, neurologists and otolaryngologists often have differing views on what is truly causing headache in the sinonasal region. This review discusses common primary headache diagnoses that can masquerade as "sinus headache" or "rhinogenic headache," such as migraine, trigeminal neuralgia, tension-type headache, temporomandibular joint dysfunction, giant cell arteritis (also known as temporal arteritis) and medication overuse headache, as well as the trigeminal autonomic cephalalgias, including cluster headache, paroxysmal hemicrania, and hemicrania continua. Diagnostic criteria are discussed and evidence outlined that allows physicians to make better clinical diagnoses and point patients toward better treatment options.

  View details for DOI 10.1016/j.otc.2013.10.008

  View details for Web of Science ID 000334894500009

  View details for PubMedID 24680494

• Practice patterns regarding noninvasive rhinosinusitis in the immunosuppressed patient population. Allergy & rhinology (Providence, R.I.) Patel, Z. M. 2013; 4 (3): e151-4

  Abstract

  The number of immunosuppressed patients is growing remarkably. Currently, there is no guideline on how treatment of noninvasive sinusitis in these patients may differ from that of the general population, and practice patterns vary widely across the country. The purpose of this survey was to examine practice patterns and management for this patient population. A survey and literature review were performed. The survey was sent to the membership list serve of the American Rhinologic Society. Twelve questions were asked. Four demographic questions were asked about the physicians and their practices. Four questions were asked about the type of immunocompromised patients they saw. Two questions were asked about management in the setting of significant acute and chronic sinusitis. The responses were collected and analyzed using Pearson independent chi-square testing. Of 871 members on the list serve only 89 physicians responded. The majority of responders were sinus and skull base surgeons practicing in an academic setting. There was a large range of geographic location, years in practice, and patient population. Two significant findings related years in practice to management of chronic sinus immunocompromised patients (p = 0.012) and correlated the choice of management option in acute and chronic sinus immunocompromised patients (p = 0.006). There is no standardized method of treating the vulnerable patient population of immunocompromised patients with noninvasive acute and chronic sinusitis and this survey shows the wide range of practice. Clinical research is needed to standardize and optimize treatment for these patients.

  View details for DOI 10.2500/ar.2013.4.0070

  View details for PubMedID 24498520

• Comparing use of the Sonopet((R)) ultrasonic bone aspirator to traditional instrumentation during the endoscopic transsphenoidal approach in pituitary tumor resection INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Baddour, H. M., Lupa, M. D., Patel, Z. M. 2013; 3 (7): 588-591

  Abstract

  The Sonopet(®) ultrasonic bone aspirator (Stryker(®) , Kalamazoo, MI) has been used within neurosurgery, otolaryngology and in other fields, but to our knowledge has not been reported in the literature for use in endoscopic transsphenoidal approaches (TSAs) to the skull base. The study objective was to compare use of the ultrasonic bone aspirator (UBA) vs traditional cold steel instrumentation during TSA in terms of operative time and blood loss.The study design was a prospective, randomized, single-blinded controlled clinical trial. The population included patients who presented to a tertiary care skull base center with pituitary tumors amenable to endoscopic resection. Participants were randomized to either an endoscopic approach using the ultrasonic bone aspirator (n = 66) or traditional steel instrumentation (n = 64). Outcomes measured were operative time and blood loss for the approach and exposure portion of the procedure.The use of the UBA resulted in a significant reduction in both operative time (31.92 ± 3.04 minutes vs 41.32 ± 2.75 minutes, p < 0.0001) and blood loss (16.5 ± 5.37 milliliters vs 22.57 ± 3.09 milliliters, p < 0.0001) compared to traditional steel instrumentation.This study is, to our knowledge, the first prospective, randomized, controlled clinical trial comparatively demonstrating the speed, safety and efficacy of the ultrasonic bone aspirator for endoscopic TSA to the skull base. Although the UBA offers surgical benefits, the cost of disposables may limit its usefulness to use in tertiary care institutions where operative cost can be shared across departments and with the hospital.

  View details for DOI 10.1002/alr.21143

  View details for Web of Science ID 000322036500011

  View details for PubMedID 23292661

• Concurrent functional endoscopic sinus surgery and septorhinoplasty: using evidence to make clinical decisions INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Patel, Z. M., Setzen, M., Sclafani, A. P., Del Gaudio, J. M. 2013; 3 (6): 488-492

  Abstract

  Concurrent septorhinoplasty (SRP) and functional endoscopic sinus surgery (FESS) has been a controversial topic in the literature over the last decade. Warnings and admonitions about the risks of performing these procedures together in a single surgery are both published and voiced at national meetings. Although pros and cons have been discussed in the literature, there have been no guidelines published based solely on a review of the level of evidence.A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were an adult population >18 years old, description or implication of study design available, concurrent FESS and SRP performed without additional procedures, and report of complications included in the study.We identified and evaluated the literature meeting those criteria: 11 retrospective studies. The literature was reviewed for both quality of research design as well as benefit and harm of the proposed interventions.If a patient is in need of FESS and SRP, either for functional or cosmetic reasons, and is found on the risk matrix to either have low or moderate risk, that patient is a good candidate for a concurrent procedure. If the patient is found to have higher risk, it is not an absolute contraindication, but the surgeon must use best clinical judgment when deciding to move forward and must counsel the patient preoperatively about possible increased risks.

  View details for DOI 10.1002/alr.21130

  View details for Web of Science ID 000320929300009

  View details for PubMedID 23293086

• "Sinus headache": rhinogenic headache or migraine? An evidence-based guide to diagnosis and treatment INTERNATIONAL FORUM OF ALLERGY & RHINOLOGY Patel, Z. M., Kennedy, D. W., Setzen, M., Poetker, D. M., DelGaudio, J. M. 2013; 3 (3): 221-230

  Abstract

  Patients present to physicians across multiple disciplines with the complaint of sinus headache. This lay term is widely accepted in the media, yet has been repeatedly questioned in the medical literature, and experts in the fields of otolaryngology, neurology, and allergy have agreed that it is an overused and often incorrect diagnosis in the majority of patients. There have been review articles and consensus panels established regarding this issue, but thus far no guidelines based purely on a review of the level of evidence provided by the literature.A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were: adult population >18 years old, self-diagnosed or physician-diagnosed "sinus headache," clearly defined diagnostic criteria in diagnostic studies, and clearly defined primary clinical end-point in therapeutic studies.We identified and evaluated the literature on diagnosing and treating patients with a primary complaint of sinus headache. The literature was reviewed for both quality of research design as well as benefit and harm of the proposed interventions.If a thorough neurologic and otolaryngologic evaluation is performed, the majority of patients presenting with sinus headache in the absence of significant acute inflammatory findings will be diagnosed with migraine. In this situation, the appropriate treatment for the majority of patients presenting with sinus headache is migraine directed therapy. In a highly select group of patients, directed nasal surgery addressing endonasal contact points may be an option.

  View details for DOI 10.1002/alr.21095

  View details for Web of Science ID 000316265000011

  View details for PubMedID 23129234

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

  Abstract

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

  View details for DOI 10.1002/alr.21039

  View details for Web of Science ID 000308927400007

  View details for PubMedID 22528624

• The Prevention and Management of Complications in Ethmoid Sinus Surgery OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Patel, Z. M., Govindaraj, S. 2010; 43 (4): 855-?

  Abstract

  Prevention of complications during ethmoid sinus surgery begins with sound knowledge of the relevant anatomy, preoperative planning with use of radiologic imaging, and careful, thoughtful dissection intraoperatively. Despite these measures, however, complications may occur. This article highlights potential complications and treatment techniques to salvage good outcomes following endoscopic ethmoidectomy.

  View details for DOI 10.1016/j.otc.2010.04.010

  View details for Web of Science ID 000280482100013

  View details for PubMedID 20599089

• The evolution of management for inverted papilloma: An analysis of 200 cases OTOLARYNGOLOGY-HEAD AND NECK SURGERY Lawson, W., Patel, Z. M. 2009; 140 (3): 330-335

  Abstract

  To assess the evolution of management within one institution with the largest case series and longest clinical follow-up of IP to date in the literature and to compare this management with what has been recently presented in publication.A case series was performed assessing sex, age, presenting symptoms, origin of lesion, staging, primary versus recurrence, radiographic findings, method of treatment, rate of recurrence, and associated malignancy.Two hundred patients (average age, 57) underwent endoscopic or endoscopic-assisted resection of IP. The mean follow-up was 4.3 years (range, 9 months-19 years). Eighty percent of cases over the last decade had prior surgery before presentation. Sixty-three percent were Krouse stage T3, and 25 percent were T4. Combined approaches were used for 57 percent of the most recent 40 cases, including Caldwell-Luc, lateral rhinotomy, medial maxillectomy, trephine, or osteoplastic flap.Inverted papilloma can be addressed endoscopically when possible, with data from this study and the current literature suggesting this is feasible in 43 percent to 66 percent of cases. This decision should be made for each individual case, and variables that will likely affect the decision to use adjuvant external approaches include significant scarring and anatomic distortion from previous surgery, high Krouse stage, and associated malignancy.

  View details for DOI 10.1016/j.otohns.2008.11.010

  View details for Web of Science ID 000263810600009

  View details for PubMedID 19248937

• The Development and Pathologic Processes that Influence Maxillary Sinus Pneumatization ANATOMICAL RECORD-ADVANCES IN INTEGRATIVE ANATOMY AND EVOLUTIONARY BIOLOGY Lawson, W., Patel, Z. M., Lin, F. Y. 2008; 291 (11): 1554-1563

  Abstract

  The maxillary sinus is universally described as a pyramidal-shaped cavity in the maxilla. Hypoplasia, which can occur unilaterally or bilaterally, is graded by the authors by the degree of failure of descent below the nasal floor in achieving its position adjacent to the posterior dentition in the adult. Unlike early studies using plain X-rays, which considered pneumatization into the zygomatic recess and dental alveolus as criteria, the authors have adopted the above-cited parameters based on computed tomography (CT) imaging, which reveals that even when smaller the sinus retains a pyramidal configuration, although truncated. Rarely, the sinus is excessively pneumatized in the nonpathologic state. Review of the literature failed to reveal a comprehensive study of the conditions that alter maxillary sinus volume and configuration. Based on a retrospective review of 6,000 high resolution CT scans of the paranasal sinuses, the types and relative incidences of these conditions have been determined, and a classification system proposed. The mixed-sex sample group (= 2,540) was comprised of nonpediatric (adolescent and adult) and was of a polyethnic composition. Results showed that enlargement of the sinus is uncommonly encountered, and is produced by air (pneumocele) and mucus (mucocele) entrapment, or by benign tumors which have arisen in the sinus or adjacent maxilla and have grown intracavitarily, with the sinus walls expanding and remodeling to accommodate them. Reduction in size and volume is more frequent. Heredo-familial syndromic conditions reduce sinus size by impaired facial growth centers, or obliteration by dense osteosclerosis. Irradiation for neoplastic disease in the pediatric population similarly, directly effect growth centers, or impairs pituitary function. Another iatrogenic cause, direct surgical intervention (Caldwell-Luc procedure) almost universally alters sinus volume and shape by osteoneogenesis. Midfacial fractures involving the sinus also produce distortion by sclerosis as well as by malpositioning of bone fragments. The principal systemic disorders, sickle cell anemia and osteopetrosis, which diffusely effect medullary bone, do so either through compensatory marrow proliferation or sclerotic new bone formation, thus serving to produce maxillary enlargement and sinus obliteration. The greatest source of maxillary sinus distortion and destruction are neoplasms. Malignant sinonasal and oral cavity tumors produce bony erosion of the sinus walls, whereas benign odontogenic cysts remain external to the sinuses and compress it as they enlarge. Most odontogenic tumors produce external compression and remodeling. Fibro-osseous disorders similarly produce size and shape distortions by external impingement. Although diverse developmental and pathological conditions influence maxillary sinus morphology, there is a limited range of biologic response.

  View details for DOI 10.1002/ar.20774

  View details for Web of Science ID 000260396400017

  View details for PubMedID 18951496