David W. Jang

Transoral Robotic Surgery Using a Carbon Dioxide Flexible Laser for Tumors of the Upper Aerodigestive Tract

Objective: To determine the safety, feasibility, and efficacy of coupling transoral robotic technology with the flexible carbon dioxide (CO2) laser for various tumors of the oropharynx and supraglottic larynx.

Budesonide nasal irrigations in the postoperative management of chronic rhinosinusitis

Nasal steroids play an important role in the postoperative management of patients with chronic rhinosinusitis (CRS). However, commercially available nasal steroid sprays may not deliver adequate amounts of medication to the entire postoperative sinus cavity. The off‐label use of budesonide nasal irrigation (BNI) theoretically solves this problem by delivering concentrated steroid solution through a high‐pressure, high‐volume system. Several studies have attested to the safety of BNI, but there are very few reports of its efficacy.

Supraorbital Ethmoid Cell A Consistent Landmark for Endoscopic Identification of the Anterior Ethmoidal Artery

Objective To demonstrate that the supraorbital ethmoid cell (SOEC) is a consistent and reliable landmark in identification of the anterior ethmoidal artery (AEA). Study Design Retrospective radiographic study. Setting Tertiary care rhinology practice. Subjects and Methods The computed tomography (CT) scans for 78 consecutive patients were evaluated for the presence of SOECs, degree of pneumatization, and location of the AEA in relation to fixed anatomic structures. Forty-one patients with normal SOECs were identified and compared with a group of 15 patients with pathological expansion of the SOEC secondary to inflammatory disease. The CT findings were correlated with endoscopic findings. Results The incidence of SOECs was 53%. Compared to normal SOECs, expanded SOECs had significantly greater pneumatization laterally (9.3 vs 18.5 mm, respectively; P < .0001) and AEAs that were significantly farther from the skull base (1.3 vs 6.6 mm, respectively; P < .0001). The distance between the AEA and the nasal beak was similar between the 2 groups (P = .1). More importantly, 68 of 68 sides with normal SOECs (100%) demonstrated the AEA within or in continuity with the posterior border of the SOEC opening. In patients with pathological expansion, the AEA remained within the posterior border of the SOEC opening in 19 of 19 sides (100%), despite significant expansion of the cell superolaterally. Conclusion This is the first study to demonstrate a consistent landmark to identify the AEA even in cases of distorted anatomy of the frontal recess. Identifying the SOEC is a practical and reliable technique for minimizing the risk of injury to the AEA during frontal recess surgery.

Aspirin sensitivity does not compromise quality-of-life outcomes in patients with samter's triad

To demonstrate that quality‐of‐life outcomes after endoscopic sinus surgery are not compromised in patients with Samters triad (asthma, nasal polyps, aspirin sensitivity) when compared to patients with eosinophilic chronic rhinosinusitis with nasal polyposis (eCRSwP) who are not aspirin sensitive.

Palliative surgery for head and neck cancer with extensive skin involvement

To evaluate the role of regional and free tissue transfer for the palliative management of head and neck cancer with extensive skin involvement.

Bony erosion patterns in patients with allergic fungal sinusitis.

Objective To investigate bony erosion patterns in allergic fungal sinusitis (AFS) and to determine whether the extent of erosion correlates with demographics and preoperative clinical parameters. Study Design Retrospective review of prospectively collected data. Methods Seventy-four patients with a histopathologic diagnosis of AFS were identified. Preoperative computed tomographies (CT) were reviewed to determine sites with bony erosion. The 20-item Sinonasal Outcomes Test (SNOT-20) scores, endoscopy scores, and Lund-Mackay CT scores were compared between patients with and without bony erosion. Patients with bony erosion were further classified based on the extent of erosion. Statistical analysis was performed by using the Students t-test and the χ2 test of independence. Results Of the 74 patients, 39 (52.7%) had bony erosion and 35 (47.3%) did not. Bony erosion was found to be associated with younger age (27.5 versus 36.0 years; p = 0.011) and African American race (p = 0.041). Preoperative CT scores correlated with the presence and extent of bony erosion (p = 0.010). Sex, race, number of previous surgeries, SNOT-20 scores, and endoscopy scores did not correlate significantly. Conclusion Younger age and African American race were found to significantly correlate with bony erosion in AFS, which indicated that a more severe inflammatory response was mounted in these patient groups. As expected, higher Lund-Mackay scores correlated with the severity of erosion. The lack of correlation with SNOT-20 scores indicated the insidious nature of this destructive disease. The level of evidence is 4.

Modeling alterations in sinonasal physiology after skull base surgery.

Background Endonasal endoscopic skull base surgery (EESBS) often requires significant alterations in intranasal anatomy. For example, posterior septectomy (PS) with middle turbinate resection (MTR) is frequently performed to provide access to large sellar and clival tumors. However, little is known about the alterations that occur in sinonasal physiology. This study was designed to assess changes in sinonasal physiology after virtually performed endoscopic skull base surgery. Methods Three-dimensional models of the sinonasal passage were created from computed tomography scans in three subjects with varying anatomy: no SD (SD), right anterior SD, and left anterior SD, respectively. Four additional surgery types were performed virtually on each model: endoscopic transsphenoidal approach (ETSA) with small (1 cm) PS (smPS), ETSA with complete (2 cm) PS, ETSA with smPS and right MTR, and ETSA with complete PS and right MTR. Computational fluid dynamics (CFD) simulations were performed on the 3 presurgery and 12 virtual surgery models to assess changes from surgery types. Results Increased nasal airflow corresponded to amount of tissue removed. Effects of MTR on unilateral airflow allocation were unchanged in subject with no SD, worsened in leftward SD, and reversed in rightward SD. Severity of airflow and mucosal wall interactions trended with amount of tissue removed. MTR hindered flow interactions with the olfactory mucosa in subjects with SD. Conclusion CFD simulations on virtual surgery models are able to reasonably detect changes in airflow patterns in the computer-generated nasal models. In addition, each patients unique anatomy influences the magnitude and direction of these changes after virtual EESBS. Once future studies can reliably correlate CFD parameters with patient symptoms, CFD will be a useful clinical tool in surgical planning and maximizing patient outcomes.

Landmarks for endoscopic approach to the parapharyngeal internal carotid artery: A radiographic and cadaveric study

To define transnasal endoscopic surgical landmarks for the parapharyngeal segment of the internal carotid artery (ppICA) using radiographic analysis and cadaveric dissection.

Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery

Evidence‐based medicine in otolaryngology literature continues to be lacking, especially with regard to new products brought to market. The marketing of products often includes statements of benefit that have limited objective support in research or literature. To address this, and to adequately determine product equivalency/superiority, careful evaluation must be made. In order to establish standards for this process in rhinology products, we directly compare three different absorbable hemostatic agents in patients with chronic rhinosinusitis (CRS) after undergoing endoscopic sinus surgery (ESS), using both objective and subjective outcomes.

Characterizing Airflow Profile in the Postoperative Maxillary Sinus by Using Computational Fluid Dynamics Modeling: A Pilot Study:

Background Maxillary antrostomy is commonly performed during endoscopic sinus surgery. Little is known about the association surrounding recalcitrant maxillary sinusitis, antrostomy size, and intranasal airflow changes. Furthermore, the interaction between sinus mucosa and airflow is poorly understood. This study used computational fluid dynamics (CFD) modeling to investigate postoperative airflow characteristics between diseased and nondiseased maxillary sinuses in subjects with recurrent disease. Methods A retrospective review of patients from a tertiary-level academic rhinology practice was performed. Seven subjects with endoscopic evidence of postoperative maxillary sinus disease that presented as chronic unilateral crusting at least 1 year after bilateral maxillary antrostomies were selected. A three-dimensional model of each subjects sinonasal cavity was created from postoperative computed tomographies and used for CFD analysis. Results Although the variables investigated between diseased and nondiseased sides were not statistically significant, the diseased side in six subjects had a smaller antrostomy, and five of these subjects had both reduced nasal unilateral airflow and increased unilateral nasal resistance on the diseased side. The ratio of posterior wall shear stress (WSS) of the maxillary sinus to the total WSS was higher on the diseased side in six subjects. Results also showed strong correlations between antrostomy and CFD variables on the diseased side than on the nondiseased side. Conclusion This pilot study showed that the majority of the simulated sinonasal models exhibited common characteristics on the side with persistent disease, such as smaller antrostomy, reduced nasal airflow, increased nasal resistance, and increased posterior WSS. Although statistical significance was not established, this study provided preliminary insight into variables to consider in a larger cohort study.