Amber Luong - Academia.edu (original) (raw)

Papers by Amber Luong

Journal of Allergy and Clinical Immunology, 2020

With the increasing recognition of the role of type 2 immune responses in chronic rhinosinusitis,... more With the increasing recognition of the role of type 2 immune responses in chronic rhinosinusitis, its severity, recurrence, and comorbidities, several biologics targeting IL-4, IL-5, and IL-13 as well as IgE have been administered in small proof-of-concept studies. Recently, the first phase 3 trials have been reported with dupilumab, an IL-4 receptor antagonist, demonstrating a significant and clinically relevant reduction of the disease burden from polyp size and sinus involvement to symptoms and smell; these changes consecutively led to an important increase in quality of life. Finally, the biologic versus placebo treatment reduced the need for systemic glucocorticosteroids and sinus surgery significantly and clinically meaningfully. Dupilumab today is registered for the treatment of chronic rhinosinusitis with nasal polyps in Europe and the United States. Within a year, 2 further phase 3 trials with omalizumab and mepolizumab will be reported. With this development, without any doubt, a new era for the treatment of severe uncontrolled chronic rhinosinusitis with nasal polyps has begun. Questions on the indication of the biologics, the selection of patients, and finally criteria for monitoring the efficacy in individual patients need to be urgently answered, and care pathways need to be established integrating the current standard of care including surgery.

Otolaryngology-Head and Neck Surgery, Aug 1, 2007

Science, Aug 16, 2013

Proteinases and the innate immune receptor Toll-like receptor 4 (TLR4) are essential for expressi... more Proteinases and the innate immune receptor Toll-like receptor 4 (TLR4) are essential for expression of allergic inflammation and diseases such as asthma. A mechanism that links these inflammatory mediators is essential for explaining the fundamental basis of allergic disease but has been elusive. Here, we demonstrate that TLR4 is activated by airway proteinase activity to initiate both allergic airway disease and antifungal immunity. These outcomes were induced by proteinase cleavage of the clotting protein fibrinogen, yielding fibrinogen cleavage products that acted as TLR4 ligands on airway epithelial cells and macrophages. Thus, allergic airway inflammation represents an antifungal defensive strategy that is driven by fibrinogen cleavage and TLR4 activation. These findings clarify the molecular basis of allergic disease and suggest new therapeutic strategies.

Laryngoscope Investigative Otolaryngology

ObjectivesCurrent evidence suggests a link between idiopathic intracranial hypertension (IIH) and... more ObjectivesCurrent evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak.MethodsA retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test.ResultsAnalysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In pa...

American Journal of Otolaryngology

BACKGROUND Cryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an... more BACKGROUND Cryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an office-based procedure for chronic rhinitis (CR). Standardized preoperative evaluation, specifically the role of computed tomography (CT) and nasal endoscopy, has yet to be defined. We report a series of patients who underwent CT and endoscopy as part of CR work-up in patients referred for CA. OBJECTIVE Highlight the importance of both nasal endoscopy and CT scan in the evaluation of CR given significant overlap of symptoms and common occurrence of related sinonasal conditions. METHODS Retrospective analysis of all patients referred to a single tertiary rhinology practice for CA was performed. RESULTS Fifteen patients were sent for CA by medical allergists. Five patients were deemed CA candidates, and 1 patient received only medical CR treatment. Four patients had evidence of incomplete prior sinus surgery and/or continued chronic rhinosinusitis on endoscopic exam. These 4 patients received a combination of medical and surgical management with either complete resolution or improvement in CR symptoms. In 3 patients, CT confirmed chronic rhinosinusitis that was not apparent on endoscopy, and received a combination of medical and surgical management with symptom improvement. In the last two patients, final diagnoses were nasal valve collapse and recurrent acute rhinosinusitis. CONCLUSIONS Referrals for CA are becoming more common and the optimal preoperative work up remains unclear. In this limited retrospective review, 67% of patients had diagnoses other than CR and thus were not deemed candidates for CA. Both CT and endoscopy are complementary to a detailed history and physical examination and can aid in CA candidate selection.

American Journal of Otolaryngology, 2021

PURPOSE To evaluate the effectiveness and ease of N95 respirator decontamination methods in a cli... more PURPOSE To evaluate the effectiveness and ease of N95 respirator decontamination methods in a clinic setting and to identify the extent of microbial colonization on respirators associated with reuse. METHODS In a prospective fashion, N95 respirators (n = 15) were randomized to a decontamination process (time, dry heat, or ultraviolet C light [UVC]) in outpatient clinics. Each respirator was re-used up to 5 separate clinic sessions. Swabs on each respirator for SARS-CoV-2, bacteria, and fungi were obtained before clinic, after clinic and post-treatment. Mask integrity was checked after each treatment (n = 68). Statistical analyses were performed to determine factors for positive samples. RESULTS All three decontamination processes reduced bacteria counts similarly. On multivariate mixed model analysis, there were an additional 8.1 colonies of bacteria (95% CI 5.7 to 10.5; p < 0.01) on the inside compared to the outside surface of the respirators. Treatment resulted in a decrease of bacterial load by 8.6 colonies (95% CI -11.6 to -5.5; p < 0.01). Although no decontamination treatment affected the respirator filtration efficiency, heat treatments were associated with the breakdown of thermoplastic elastomer straps. Contamination with fungal and SARS-CoV-2 viral particles were minimal to non-existent. CONCLUSIONS Time, heat and UVC all reduced bacterial load on reused N95 respirators. Fungal contamination was minimal. Heat could permanently damage some elastic straps making the respirators nonfunctional. Given its effectiveness against microbes, lack of damage to re-treated respirators and logistical ease, UVC represents an optimal decontamination method for individual N95 respirators when reuse is necessary.

International Forum of Allergy & Rhinology, 2020

Nonallergic rhinitis (NAR) is currently a diagnosis of exclusion with an unclear pathophysiologic... more Nonallergic rhinitis (NAR) is currently a diagnosis of exclusion with an unclear pathophysiologic mechanism and limited treatment options. In patients diagnosed with NAR based on symptoms, negative skin testing and positive optical rhinometry (ORM), the study's objective was to evaluate the therapeutic action of intranasal capsaicin in the management of rhinitic symptoms and the effect on ORM readings.

International Forum of Allergy & Rhinology, 2022

International Forum of Allergy & Rhinology, 2021

BACKGROUND Endoscopic sinus surgery (ESS) and septoplasty are commonly performed procedures witho... more BACKGROUND Endoscopic sinus surgery (ESS) and septoplasty are commonly performed procedures without standardized post-operative pain regimens. There is reluctance to prescribe opioids for postoperative pain given their potential for abuse. NSAIDS have been previously demonstrated to reduce or even obviate the need for opioid pain medications after otolaryngologic surgeries, but prospective validation is lacking. METHODS A randomized controlled study comparing the efficacy of diclofenac sodium to hydrocodone/acetaminophen (APAP) following ESS with or without septoplasty was performed. Participants were given a 100 mm visual analog pain scale (VAS) at postoperative day (POD) 1, 2, 3, and 5 following ESS. Two-sample t-tests were used to compare pain scores between groups. RESULTS One hundred patients enrolled, and 74 patients provided pain scores to the survey. Pain was greatest for both groups on postoperative day one. Treatment with diclofenac sodium versus hydrocodone/APAP did not statistically impact pain scores at POD 1, 2, 3, or 5. No cases of epistaxis requiring an emergency room visit or return to the operating room were noted during the study period. CONCLUSIONS Diclofenac sodium may be non-inferior to hydrocodone/APAP in treating pain after ESS with or without septoplasty in opioid naïve patients without preexisting pain conditions. Further studies with larger samples are warranted to investigate the potential superiority of diclofenac to hydrocodone/APAP in certain patients after ESS and septoplasty. This article is protected by copyright. All rights reserved.

Atlas of Endoscopic Sinus and Skull Base Surgery, 2019

Abstract Endoscopic sphenopalatine artery ligation has become the standard surgical therapy for p... more Abstract Endoscopic sphenopalatine artery ligation has become the standard surgical therapy for posterior epistaxis refractory to nasal packing. A thorough understanding of the arterial blood supply to the nasal cavity is necessary for optimal surgical results. The crista ethmoidalis is the key landmark for identification of the sphenopalatine foramen. The sphenopalatine artery branches may be controlled with hemoclips, bipolar cautery, or both. Recent cost-benefit and cost-utility analyses have suggested endoscopic sphenopalatine artery ligation may be considered earlier in the epistaxis treatment algorithm.

Annals of Otology, Rhinology & Laryngology, 2021

Background: Reliable use of surgical navigation depends upon the registration process. The gold s... more Background: Reliable use of surgical navigation depends upon the registration process. The gold standard is paired-point registration with bone-anchored fiducials, but contour-map registration is more practical. Surgeons may employ variable contour maps and less experienced team members often perform this critical step. The impact of these practices on target registration error (TRE) is not well-studied. Methods: A dry lab set-up consisting of a navigation system (Fusion ENT, Medtronic, Jacksonville, FL) and a sinus phantom with 2 mm radiopaque spheres in the sphenoid and ethmoid regions was developed. A CT (0.625 mm slice thickness) was obtained. Registration was performed with a contour-based protocol. Accuracy was determined using the software’s distance measurement tool. Registration was performed with narrow-field (NF; forehead points medial to the mid-pupillary line) and wide field (WF; entire forehead) contour maps. An experienced rhinologist and a resident surgeon performed ...

International Forum of Allergy & Rhinology, 2021

Surgical extirpation remains the preferred primary treatment of carcinomas in the sinonasal cavit... more Surgical extirpation remains the preferred primary treatment of carcinomas in the sinonasal cavity.1 Locally advanced malignancies that have extraconal orbital invasion have presented a significant treatment challenge especially in patients without visual impairment. Traditionally, orbital exenteration has been the standard approach for the treatment of locally advanced malignancies in this region, but this comes at a significantmorbidity to the patient with loss of binocular vision, as well as longterm psychosocial ramifications.2 Minimally-invasive transorbital-transsinus (TOTS) resection performed utilizing a two-surgeon team of an otorhinolaryngologist and oculoplastic surgeon may offer sound surgical resection while preserving ocular function when used in conjunction with multimodality therapy. Although purely endoscopic or combined approaches have been discussed for nonmalignant orbital pathology,3,4 limited data is published for sinonasal malignancy with orbital invasion. The TOTS procedure commences with an extended, endoscopic, transnasal resection of the neoplasm. Surgical navigation is routinely employed, often with fused computed tomography (CT) and magnetic resonance imaging (MRI) images. Typically, endoscopic medial maxillectomy or a modified endoscopic Denker’s approach is employed for creation of the maximal optical space for visualization of the orbit with the degree of dissection dependent upon tumor burden. Tumor is cleared endoscopically from the sinonasal cavity until the medial and inferior orbital walls have been isolated. The oculoplastic surgeon then performs a transcaruncular and/or transconjunctival orbitotomy, through which healthy orbital soft tissues are protected.With visualization throughboth the orbitotomy and endoscopic sinonasal corridor, the oculoplastic surgeon and otorhinolaryngologist together resect residual tumor from the medial and inferior aspects of the orbit. By working through both the transsinus and transorbital route, the surgical team can better judge the extent of surgical resection, while the oculoplastic surgeon can protect the normal soft-tissues of the orbit.3,4 In addition, this creates a surgical advantage in this location allowing for alternating traction and countertraction through both corridors to remove tumor using through-cutting, grasping, or powered instrumentation. The infraorbital neurovascular bundle and/or inferior obliquemuscle may be sacrificed for margin clearance. A diamond-tipped drill is used to clear bone margins and to expand the corridor for access. Reconstruction of the bony defect, if indicated, is completed with an alloplastic or titanium implant, and the orbital incisions are closed. Figure 1 shows representative images of the TOTS procedure. This case series presents the outcomes of five patients (mean age 65 years; range, 50–78 years) who underwent eight TOTS procedures for locally advanced maxillary and

Annals of Otology, Rhinology & Laryngology, 2020

Background: Extended endoscopic transsphenoidal (EET) approaches can include complete resection o... more Background: Extended endoscopic transsphenoidal (EET) approaches can include complete resection of both superior turbinate (ST) for wider exposure. Moreover, ST resection has been associated with postoperative olfactory impairment. Objective: We sought to determine the impact of bilateral ST resection on olfaction during a transsphenoidal approach. Method: A prospective observational study was conducted on 29 patients undergoing endoscopic skull base surgery sparing the olfactory tracts at a tertiary academic center. Olfactory function was measured with Sniffin’ Sticks at the preoperative visit, 2-weeks and 6 to 8 weeks postoperatively. All components: odor threshold (OT), odor discrimination (OD), odor identification (OI) and composite scores (TDI = OT+OD+OI) were evaluated. Result: Study was completed in 15 patients with 14 excluded due to a variety of reasons. At 2 weeks, a significant decrease was noted in composite scores (32.3 ± 5.4 vs. 23.8 ± 5.8, P < .05) and OT (7.7 vs. ...

Ear, Nose & Throat Journal, 2020

Introduction: Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology ... more Introduction: Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes. Objectives: Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies. Methods: English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advance...

Otolaryngology–Head and Neck Surgery, 2019

ObjectiveChronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the preva... more ObjectiveChronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire–9 (PHQ‐9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ‐9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ‐9 with the 22‐item Sinonasal Outcome Test (SNOT‐22).Study DesignRetrospective chart review.SettingTertiary rhinology practice.Subjects and MethodsDuring the 2‐month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ‐9 and SNOT‐22.ResultsAmong 216 patients, 46 (21.3%) had a self‐reported history of depression, and 39 (18.1%) had a PHQ‐9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison o...

OTO Open, 2019

ObjectiveMicrobiome analyses now allow precise determination of the sinus microbiota of patients ... more ObjectiveMicrobiome analyses now allow precise determination of the sinus microbiota of patients with exacerbations of chronic rhinosinusitis (CRS). The aim of this report is to describe the sinus microbiota of acute exacerbations in CRS clinical subgroups (with nasal polyps [CRSwNP], without nasal polyps [CRSsNP], and allergic fungal rhinosinusitis [AFRS]).Study DesignRetrospective chart review.SettingTertiary rhinology practice.Subjects and MethodsA retrospective review was performed of all patients whose sinus microbiota were assayed via a commercially available microbiome technology during an acute CRS exacerbation during the 2‐year period ending December 31, 2016. All samples were sinus aspirates collected under endoscopic visualization in clinic.ResultsSamples from a total of 134 patients (65 CRSsNP, 55 CRSwNP, and 14 AFRS) were reviewed. The observed richness (number of taxa >2% relative abundance) ranged between 1 and 11 taxa, with an average of 3 taxa per specimen. The m...

Otolaryngology–Head and Neck Surgery, 2019

ObjectiveHigh‐throughput DNA sequencing of the paranasal sinus microbiome has potential in the di... more ObjectiveHigh‐throughput DNA sequencing of the paranasal sinus microbiome has potential in the diagnosis and treatment of sinusitis. The objective of this study is to evaluate the use of high‐throughput DNA sequencing to diagnose sinusitis of odontogenic origin.Study DesignCase series with chart review.SettingSingle tertiary care academic medical center.Subjects and MethodsA chart review was performed of DNA sequencing results from the sinus aspirates obtained under endoscopic visualization in 142 patients with sinusitis. The identification of any potentially pathogenic bacteria associated with oral flora in a sample was classified as a positive result for sinusitis of odontogenic etiology. The sensitivity, specificity, and predictive values of using high‐throughput DNA sequencing to diagnose sinusitis of odontogenic etiology were determined, with the patient’s computed tomography sinus scan as the reference standard. On computed tomography scans, an odontogenic source was determine...

International Forum of Allergy & Rhinology, 2018

Otolaryngologic Clinics of North America, 2019

Office-based rhinologic procedures have seen a dramatic rise in incidence over the last decade. I... more Office-based rhinologic procedures have seen a dramatic rise in incidence over the last decade. It is crucial to select appropriate patients and understand which pathologies may be amenable to in-office procedures. It behooves the otolaryngologist to be familiar with the array of technologic advances that are expanding the limits of office-based rhinology and to have a solid understanding of the technical nuances of using these technologies in the clinic. This article highlights the issues associated with some of the more common office-based sinus procedures, and provides practical information on set-up and reimbursement.

This study offers a novel description of the sinonasal microbiome, through an unsupervised machin... more This study offers a novel description of the sinonasal microbiome, through an unsupervised machine learning approach combining dimensionality reduction and clustering. We apply our method to the International Sinonasal Microbiome Study (ISMS) dataset of 410 sinus swab samples. We propose three main sinonasal microbiotypes or states: the first is Corynebacterium-dominated, the second is Staphylococcus-dominated, and the third dominated by the other core genera of the sinonasal microbiome (Streptococcus, Haemophilus, Moraxella, and Pseudomonas). The prevalence of the three microbiotypes studied did not differ between healthy and diseased sinuses, but differences in their distribution were evident based on geography. We also describe a potential reciprocal relationship between Corynebacterium species and Staphylococcus aureus, suggesting that a certain microbial equilibrium between various players is reached in the sinuses. We validate our approach by applying it to a separate 16S rRNA...

Journal of Allergy and Clinical Immunology, 2020

With the increasing recognition of the role of type 2 immune responses in chronic rhinosinusitis,... more With the increasing recognition of the role of type 2 immune responses in chronic rhinosinusitis, its severity, recurrence, and comorbidities, several biologics targeting IL-4, IL-5, and IL-13 as well as IgE have been administered in small proof-of-concept studies. Recently, the first phase 3 trials have been reported with dupilumab, an IL-4 receptor antagonist, demonstrating a significant and clinically relevant reduction of the disease burden from polyp size and sinus involvement to symptoms and smell; these changes consecutively led to an important increase in quality of life. Finally, the biologic versus placebo treatment reduced the need for systemic glucocorticosteroids and sinus surgery significantly and clinically meaningfully. Dupilumab today is registered for the treatment of chronic rhinosinusitis with nasal polyps in Europe and the United States. Within a year, 2 further phase 3 trials with omalizumab and mepolizumab will be reported. With this development, without any doubt, a new era for the treatment of severe uncontrolled chronic rhinosinusitis with nasal polyps has begun. Questions on the indication of the biologics, the selection of patients, and finally criteria for monitoring the efficacy in individual patients need to be urgently answered, and care pathways need to be established integrating the current standard of care including surgery.

Otolaryngology-Head and Neck Surgery, Aug 1, 2007

Science, Aug 16, 2013

Proteinases and the innate immune receptor Toll-like receptor 4 (TLR4) are essential for expressi... more Proteinases and the innate immune receptor Toll-like receptor 4 (TLR4) are essential for expression of allergic inflammation and diseases such as asthma. A mechanism that links these inflammatory mediators is essential for explaining the fundamental basis of allergic disease but has been elusive. Here, we demonstrate that TLR4 is activated by airway proteinase activity to initiate both allergic airway disease and antifungal immunity. These outcomes were induced by proteinase cleavage of the clotting protein fibrinogen, yielding fibrinogen cleavage products that acted as TLR4 ligands on airway epithelial cells and macrophages. Thus, allergic airway inflammation represents an antifungal defensive strategy that is driven by fibrinogen cleavage and TLR4 activation. These findings clarify the molecular basis of allergic disease and suggest new therapeutic strategies.

Laryngoscope Investigative Otolaryngology

ObjectivesCurrent evidence suggests a link between idiopathic intracranial hypertension (IIH) and... more ObjectivesCurrent evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak.MethodsA retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test.ResultsAnalysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In pa...

American Journal of Otolaryngology

BACKGROUND Cryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an... more BACKGROUND Cryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an office-based procedure for chronic rhinitis (CR). Standardized preoperative evaluation, specifically the role of computed tomography (CT) and nasal endoscopy, has yet to be defined. We report a series of patients who underwent CT and endoscopy as part of CR work-up in patients referred for CA. OBJECTIVE Highlight the importance of both nasal endoscopy and CT scan in the evaluation of CR given significant overlap of symptoms and common occurrence of related sinonasal conditions. METHODS Retrospective analysis of all patients referred to a single tertiary rhinology practice for CA was performed. RESULTS Fifteen patients were sent for CA by medical allergists. Five patients were deemed CA candidates, and 1 patient received only medical CR treatment. Four patients had evidence of incomplete prior sinus surgery and/or continued chronic rhinosinusitis on endoscopic exam. These 4 patients received a combination of medical and surgical management with either complete resolution or improvement in CR symptoms. In 3 patients, CT confirmed chronic rhinosinusitis that was not apparent on endoscopy, and received a combination of medical and surgical management with symptom improvement. In the last two patients, final diagnoses were nasal valve collapse and recurrent acute rhinosinusitis. CONCLUSIONS Referrals for CA are becoming more common and the optimal preoperative work up remains unclear. In this limited retrospective review, 67% of patients had diagnoses other than CR and thus were not deemed candidates for CA. Both CT and endoscopy are complementary to a detailed history and physical examination and can aid in CA candidate selection.

American Journal of Otolaryngology, 2021

PURPOSE To evaluate the effectiveness and ease of N95 respirator decontamination methods in a cli... more PURPOSE To evaluate the effectiveness and ease of N95 respirator decontamination methods in a clinic setting and to identify the extent of microbial colonization on respirators associated with reuse. METHODS In a prospective fashion, N95 respirators (n = 15) were randomized to a decontamination process (time, dry heat, or ultraviolet C light [UVC]) in outpatient clinics. Each respirator was re-used up to 5 separate clinic sessions. Swabs on each respirator for SARS-CoV-2, bacteria, and fungi were obtained before clinic, after clinic and post-treatment. Mask integrity was checked after each treatment (n = 68). Statistical analyses were performed to determine factors for positive samples. RESULTS All three decontamination processes reduced bacteria counts similarly. On multivariate mixed model analysis, there were an additional 8.1 colonies of bacteria (95% CI 5.7 to 10.5; p < 0.01) on the inside compared to the outside surface of the respirators. Treatment resulted in a decrease of bacterial load by 8.6 colonies (95% CI -11.6 to -5.5; p < 0.01). Although no decontamination treatment affected the respirator filtration efficiency, heat treatments were associated with the breakdown of thermoplastic elastomer straps. Contamination with fungal and SARS-CoV-2 viral particles were minimal to non-existent. CONCLUSIONS Time, heat and UVC all reduced bacterial load on reused N95 respirators. Fungal contamination was minimal. Heat could permanently damage some elastic straps making the respirators nonfunctional. Given its effectiveness against microbes, lack of damage to re-treated respirators and logistical ease, UVC represents an optimal decontamination method for individual N95 respirators when reuse is necessary.

International Forum of Allergy & Rhinology, 2020

Nonallergic rhinitis (NAR) is currently a diagnosis of exclusion with an unclear pathophysiologic... more Nonallergic rhinitis (NAR) is currently a diagnosis of exclusion with an unclear pathophysiologic mechanism and limited treatment options. In patients diagnosed with NAR based on symptoms, negative skin testing and positive optical rhinometry (ORM), the study's objective was to evaluate the therapeutic action of intranasal capsaicin in the management of rhinitic symptoms and the effect on ORM readings.

International Forum of Allergy & Rhinology, 2022

International Forum of Allergy & Rhinology, 2021

BACKGROUND Endoscopic sinus surgery (ESS) and septoplasty are commonly performed procedures witho... more BACKGROUND Endoscopic sinus surgery (ESS) and septoplasty are commonly performed procedures without standardized post-operative pain regimens. There is reluctance to prescribe opioids for postoperative pain given their potential for abuse. NSAIDS have been previously demonstrated to reduce or even obviate the need for opioid pain medications after otolaryngologic surgeries, but prospective validation is lacking. METHODS A randomized controlled study comparing the efficacy of diclofenac sodium to hydrocodone/acetaminophen (APAP) following ESS with or without septoplasty was performed. Participants were given a 100 mm visual analog pain scale (VAS) at postoperative day (POD) 1, 2, 3, and 5 following ESS. Two-sample t-tests were used to compare pain scores between groups. RESULTS One hundred patients enrolled, and 74 patients provided pain scores to the survey. Pain was greatest for both groups on postoperative day one. Treatment with diclofenac sodium versus hydrocodone/APAP did not statistically impact pain scores at POD 1, 2, 3, or 5. No cases of epistaxis requiring an emergency room visit or return to the operating room were noted during the study period. CONCLUSIONS Diclofenac sodium may be non-inferior to hydrocodone/APAP in treating pain after ESS with or without septoplasty in opioid naïve patients without preexisting pain conditions. Further studies with larger samples are warranted to investigate the potential superiority of diclofenac to hydrocodone/APAP in certain patients after ESS and septoplasty. This article is protected by copyright. All rights reserved.

Atlas of Endoscopic Sinus and Skull Base Surgery, 2019

Abstract Endoscopic sphenopalatine artery ligation has become the standard surgical therapy for p... more Abstract Endoscopic sphenopalatine artery ligation has become the standard surgical therapy for posterior epistaxis refractory to nasal packing. A thorough understanding of the arterial blood supply to the nasal cavity is necessary for optimal surgical results. The crista ethmoidalis is the key landmark for identification of the sphenopalatine foramen. The sphenopalatine artery branches may be controlled with hemoclips, bipolar cautery, or both. Recent cost-benefit and cost-utility analyses have suggested endoscopic sphenopalatine artery ligation may be considered earlier in the epistaxis treatment algorithm.

Annals of Otology, Rhinology & Laryngology, 2021

Background: Reliable use of surgical navigation depends upon the registration process. The gold s... more Background: Reliable use of surgical navigation depends upon the registration process. The gold standard is paired-point registration with bone-anchored fiducials, but contour-map registration is more practical. Surgeons may employ variable contour maps and less experienced team members often perform this critical step. The impact of these practices on target registration error (TRE) is not well-studied. Methods: A dry lab set-up consisting of a navigation system (Fusion ENT, Medtronic, Jacksonville, FL) and a sinus phantom with 2 mm radiopaque spheres in the sphenoid and ethmoid regions was developed. A CT (0.625 mm slice thickness) was obtained. Registration was performed with a contour-based protocol. Accuracy was determined using the software’s distance measurement tool. Registration was performed with narrow-field (NF; forehead points medial to the mid-pupillary line) and wide field (WF; entire forehead) contour maps. An experienced rhinologist and a resident surgeon performed ...

International Forum of Allergy & Rhinology, 2021

Surgical extirpation remains the preferred primary treatment of carcinomas in the sinonasal cavit... more Surgical extirpation remains the preferred primary treatment of carcinomas in the sinonasal cavity.1 Locally advanced malignancies that have extraconal orbital invasion have presented a significant treatment challenge especially in patients without visual impairment. Traditionally, orbital exenteration has been the standard approach for the treatment of locally advanced malignancies in this region, but this comes at a significantmorbidity to the patient with loss of binocular vision, as well as longterm psychosocial ramifications.2 Minimally-invasive transorbital-transsinus (TOTS) resection performed utilizing a two-surgeon team of an otorhinolaryngologist and oculoplastic surgeon may offer sound surgical resection while preserving ocular function when used in conjunction with multimodality therapy. Although purely endoscopic or combined approaches have been discussed for nonmalignant orbital pathology,3,4 limited data is published for sinonasal malignancy with orbital invasion. The TOTS procedure commences with an extended, endoscopic, transnasal resection of the neoplasm. Surgical navigation is routinely employed, often with fused computed tomography (CT) and magnetic resonance imaging (MRI) images. Typically, endoscopic medial maxillectomy or a modified endoscopic Denker’s approach is employed for creation of the maximal optical space for visualization of the orbit with the degree of dissection dependent upon tumor burden. Tumor is cleared endoscopically from the sinonasal cavity until the medial and inferior orbital walls have been isolated. The oculoplastic surgeon then performs a transcaruncular and/or transconjunctival orbitotomy, through which healthy orbital soft tissues are protected.With visualization throughboth the orbitotomy and endoscopic sinonasal corridor, the oculoplastic surgeon and otorhinolaryngologist together resect residual tumor from the medial and inferior aspects of the orbit. By working through both the transsinus and transorbital route, the surgical team can better judge the extent of surgical resection, while the oculoplastic surgeon can protect the normal soft-tissues of the orbit.3,4 In addition, this creates a surgical advantage in this location allowing for alternating traction and countertraction through both corridors to remove tumor using through-cutting, grasping, or powered instrumentation. The infraorbital neurovascular bundle and/or inferior obliquemuscle may be sacrificed for margin clearance. A diamond-tipped drill is used to clear bone margins and to expand the corridor for access. Reconstruction of the bony defect, if indicated, is completed with an alloplastic or titanium implant, and the orbital incisions are closed. Figure 1 shows representative images of the TOTS procedure. This case series presents the outcomes of five patients (mean age 65 years; range, 50–78 years) who underwent eight TOTS procedures for locally advanced maxillary and

Annals of Otology, Rhinology & Laryngology, 2020

Background: Extended endoscopic transsphenoidal (EET) approaches can include complete resection o... more Background: Extended endoscopic transsphenoidal (EET) approaches can include complete resection of both superior turbinate (ST) for wider exposure. Moreover, ST resection has been associated with postoperative olfactory impairment. Objective: We sought to determine the impact of bilateral ST resection on olfaction during a transsphenoidal approach. Method: A prospective observational study was conducted on 29 patients undergoing endoscopic skull base surgery sparing the olfactory tracts at a tertiary academic center. Olfactory function was measured with Sniffin’ Sticks at the preoperative visit, 2-weeks and 6 to 8 weeks postoperatively. All components: odor threshold (OT), odor discrimination (OD), odor identification (OI) and composite scores (TDI = OT+OD+OI) were evaluated. Result: Study was completed in 15 patients with 14 excluded due to a variety of reasons. At 2 weeks, a significant decrease was noted in composite scores (32.3 ± 5.4 vs. 23.8 ± 5.8, P < .05) and OT (7.7 vs. ...

Ear, Nose & Throat Journal, 2020

Introduction: Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology ... more Introduction: Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes. Objectives: Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies. Methods: English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advance...

Otolaryngology–Head and Neck Surgery, 2019

ObjectiveChronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the preva... more ObjectiveChronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire–9 (PHQ‐9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ‐9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ‐9 with the 22‐item Sinonasal Outcome Test (SNOT‐22).Study DesignRetrospective chart review.SettingTertiary rhinology practice.Subjects and MethodsDuring the 2‐month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ‐9 and SNOT‐22.ResultsAmong 216 patients, 46 (21.3%) had a self‐reported history of depression, and 39 (18.1%) had a PHQ‐9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison o...

OTO Open, 2019

ObjectiveMicrobiome analyses now allow precise determination of the sinus microbiota of patients ... more ObjectiveMicrobiome analyses now allow precise determination of the sinus microbiota of patients with exacerbations of chronic rhinosinusitis (CRS). The aim of this report is to describe the sinus microbiota of acute exacerbations in CRS clinical subgroups (with nasal polyps [CRSwNP], without nasal polyps [CRSsNP], and allergic fungal rhinosinusitis [AFRS]).Study DesignRetrospective chart review.SettingTertiary rhinology practice.Subjects and MethodsA retrospective review was performed of all patients whose sinus microbiota were assayed via a commercially available microbiome technology during an acute CRS exacerbation during the 2‐year period ending December 31, 2016. All samples were sinus aspirates collected under endoscopic visualization in clinic.ResultsSamples from a total of 134 patients (65 CRSsNP, 55 CRSwNP, and 14 AFRS) were reviewed. The observed richness (number of taxa >2% relative abundance) ranged between 1 and 11 taxa, with an average of 3 taxa per specimen. The m...

Otolaryngology–Head and Neck Surgery, 2019

ObjectiveHigh‐throughput DNA sequencing of the paranasal sinus microbiome has potential in the di... more ObjectiveHigh‐throughput DNA sequencing of the paranasal sinus microbiome has potential in the diagnosis and treatment of sinusitis. The objective of this study is to evaluate the use of high‐throughput DNA sequencing to diagnose sinusitis of odontogenic origin.Study DesignCase series with chart review.SettingSingle tertiary care academic medical center.Subjects and MethodsA chart review was performed of DNA sequencing results from the sinus aspirates obtained under endoscopic visualization in 142 patients with sinusitis. The identification of any potentially pathogenic bacteria associated with oral flora in a sample was classified as a positive result for sinusitis of odontogenic etiology. The sensitivity, specificity, and predictive values of using high‐throughput DNA sequencing to diagnose sinusitis of odontogenic etiology were determined, with the patient’s computed tomography sinus scan as the reference standard. On computed tomography scans, an odontogenic source was determine...

International Forum of Allergy & Rhinology, 2018

Otolaryngologic Clinics of North America, 2019

Office-based rhinologic procedures have seen a dramatic rise in incidence over the last decade. I... more Office-based rhinologic procedures have seen a dramatic rise in incidence over the last decade. It is crucial to select appropriate patients and understand which pathologies may be amenable to in-office procedures. It behooves the otolaryngologist to be familiar with the array of technologic advances that are expanding the limits of office-based rhinology and to have a solid understanding of the technical nuances of using these technologies in the clinic. This article highlights the issues associated with some of the more common office-based sinus procedures, and provides practical information on set-up and reimbursement.

This study offers a novel description of the sinonasal microbiome, through an unsupervised machin... more This study offers a novel description of the sinonasal microbiome, through an unsupervised machine learning approach combining dimensionality reduction and clustering. We apply our method to the International Sinonasal Microbiome Study (ISMS) dataset of 410 sinus swab samples. We propose three main sinonasal microbiotypes or states: the first is Corynebacterium-dominated, the second is Staphylococcus-dominated, and the third dominated by the other core genera of the sinonasal microbiome (Streptococcus, Haemophilus, Moraxella, and Pseudomonas). The prevalence of the three microbiotypes studied did not differ between healthy and diseased sinuses, but differences in their distribution were evident based on geography. We also describe a potential reciprocal relationship between Corynebacterium species and Staphylococcus aureus, suggesting that a certain microbial equilibrium between various players is reached in the sinuses. We validate our approach by applying it to a separate 16S rRNA...