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Yong M, Aravinthan K, Kirubalingam K, Thamboo A, Hwang PH, Nadeau K, Walgama E. Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis. Laryngoscope 2024; 134:1572-1580. [PMID: 37642388 DOI: 10.1002/lary.31003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/14/2023] [Accepted: 08/09/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Allergic rhinitis (AR) is a common condition that is frequently associated with atopic inferior turbinate hypertrophy (ITH) resulting in nasal obstruction. Current guidelines support the use of subcutaneous allergen immunotherapy (SCIT) when patients fail pharmacologic management. However, there is a lack of consensus regarding the role of inferior turbinate reduction (ITR), a treatment that we hypothesize is cost-effective compared with other available treatments. METHODS We conducted a cost-effectiveness analysis comparing the following treatment combinations over a 5-year time horizon for AR patients presenting with atopic nasal obstruction who fail initial pharmacotherapy: (1) continued pharmacotherapy alone, (2) allergy testing and SCIT, (3) allergy testing and SCIT and then ITR for SCIT nonresponders, and (4) ITR and then allergy testing and SCIT for ITR nonresponders. Results were reported as incremental cost-effectiveness ratios (ICERs). RESULTS For patients who fail initial pharmacotherapy, prioritizing ITR, either by microdebrider-assisting submucous resection or radiofrequency ablation, before SCIT was the most cost-effective strategy. Probabilistic sensitivity analysis demonstrated that prioritizing ITR before SCIT was the most cost-effective option in 95.4% of scenarios. ITR remained cost-effective even with the addition of concurrent septoplasty. CONCLUSION For many AR patients who present with nasal obstruction secondary to atopic inferior turbinate hypertrophy that is persistent despite pharmacotherapy, ITR is a cost-effective treatment that should be considered prior to immunotherapy. LEVEL OF EVIDENCE NA - Laryngoscope, 2023 Laryngoscope, 134:1572-1580, 2024.
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Affiliation(s)
- Michael Yong
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Kaishan Aravinthan
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | | | - Andrew Thamboo
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Peter H Hwang
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Kari Nadeau
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, U.S.A
| | - Evan Walgama
- Pacific Neuroscience Institute, Santa Monica, California, U.S.A
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Yong M, Aravinthan K, Kirubalingam K, Thamboo A, Hwang PH, Nadeau K, Walgama E. In Response to Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis. Laryngoscope 2024; 134:E14-E15. [PMID: 38153190 DOI: 10.1002/lary.31247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Michael Yong
- Pacific Neuroscience Institute, Santa Monica, California, U.S.A
| | - Kaishan Aravinthan
- Division of Otolaryngology-Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | | | - Andrew Thamboo
- Division of Otolaryngology-Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Kari Nadeau
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, U.S.A
| | - Evan Walgama
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai, Los Angeles, California, U.S.A
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Abstract
Medullary thyroid cancer is a rare thyroid malignancy with unique management considerations. In general, small intrathyroidal tumors are cured by total thyroidectomy with central compartment dissection, while large tumors and those with disease spread to regional lymph nodes and distant organs (most commonly lung, liver, and bone) are more difficult to cure. The last decade has seen significant progress in the treatment of advanced MTC, largely due to the discovery and availability of novel targeted therapies, including new drugs specifically targeting the RET protooncogone.
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Affiliation(s)
- Evan Walgama
- Saint John's Cancer Institute & Pacific Neuroscience Institute, Providence Health System, 2125 Arizona Avenue, Santa Monica, CA 90404, USA
| | - Naifa Busaidy
- Department of Endocrine Neoplasia, MD Anderson Cancer Center, 1515 Holcombe Boulevard #853, Houston, TX 77030, USA
| | - Mark Zafereo
- Department of Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard Unit 1445, Houston, TX 77030, USA.
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Yong M, Wu YQ, Howlett J, Ballreich J, Walgama E, Thamboo A. Cost-effectiveness analysis comparing dupilumab and aspirin desensitization therapy for chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease. Int Forum Allergy Rhinol 2021; 11:1626-1636. [PMID: 34309219 DOI: 10.1002/alr.22865] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyposis (CRSwNP) in the setting of aspirin-exacerbated respiratory disease (AERD) is a disease that is difficult to treat and prone to recurrence. Dupilumab is a promising treatment for these patients, but its cost-effectiveness has not yet been compared with aspirin (acetylsalicyclic acid, or ASA) desensitization, a known and effective treatment. We aimed to compare the cost-effectiveness of ASA desensitization with dupilumab therapy for the treatment of CRSwNP in AERD. METHODS Analyses of cost-effectiveness, as measured in quality-adjusted life years (QALYs), and cost-utility, as measured in number of required revision endoscopic sinus surgeries (ESSs), were conducted. RESULTS ASA desensitization after ESS was cost-effective and dominated appropriate medical management. Adding salvage dupilumab was also cost-effective (incremental cost-effectiveness ratio [ICER] $135,517.33), and upfront dupilumab therapy was not cost-effective in any scenario (ICER $273,181.32). The cost-utility analysis demonstrated that, over a 10-year period per patient, appropriate medical management after ESS cost $54,125.31 and resulted in 2.25 revision ESSs, ASA desensitization after ESS cost $53,775.15 and resulted in 2.02 revision ESSs, ASA desensitization with salvage dupilumab cost $121,176.25 and resulted in 1.68 revision ESSs, and upfront dupilumab cost $185,950.34 and resulted in 1.51 revision ESSs. CONCLUSION Dupilumab for the treatment of severe CRSwNP was found to be cost-effective as salvage therapy under the willingness-to-pay threshold of $150,000. Further analysis highlighted that the cost-effectiveness of dupilumab was most sensitive to drug price and expected gains in quality of life. This suggests that additional investigation into improving patient population selection and tailoring treatment algorithms may improve the cost-effectiveness of dupilumab in specific scenarios.
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Affiliation(s)
- Michael Yong
- Faculty of Medicine, Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Yu Qi Wu
- Faculty of Medicine, Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joel Howlett
- Faculty of Medicine, Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Jeromie Ballreich
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Evan Walgama
- Division of Head & Neck Surgery, MD Anderson Cancer Center, Houston, TX
| | - Andrew Thamboo
- Faculty of Medicine, Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
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Yong M, Wu YQ, Su S, Hanna E, Prisman E, Thamboo A, Walgama E. The effect of prior radiation on the success of ventral skull base reconstruction: A systematic review and meta-analysis. Head Neck 2021; 43:2795-2806. [PMID: 33973680 DOI: 10.1002/hed.26709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/07/2021] [Indexed: 11/08/2022] Open
Abstract
The incidence of cerebrospinal fluid leak after ventral skull base reconstruction is a primary outcome of interest to skull base surgeons. Exposure to pre-operative radiation may put patients at an increased risk of skull base reconstructive failure. A systematic search identified studies which included patients receiving ventral skull base reconstruction in the setting of pre-operative radiation. A meta-analysis using a random effects model was conducted to estimate an odds ratio of cerebrospinal fluid (CSF) leak in patients exposed to pre-operative radiation. A meta-analysis of 13 studies demonstrated that the odds ratio of CSF leak was 1.73 (95% CI 0.98-3.05). The majority of studies (77%) used vascularized tissue grafts for reconstruction. We identified an increased incidence of CSF leak among patients undergoing ventral skull base reconstruction after prior radiation therapy, although not of statistical significance. Skull base surgeons should exercise caution when planning reconstruction in this population.
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Affiliation(s)
- Michael Yong
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Yu Qi Wu
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Shirley Su
- Department of Otolaryngology - Head & Neck Surgery, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ehab Hanna
- Department of Otolaryngology - Head & Neck Surgery, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eitan Prisman
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Andrew Thamboo
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Evan Walgama
- Department of Otolaryngology - Head & Neck Surgery, M. D. Anderson Cancer Center, Houston, Texas, USA
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Maul X, Dincer BC, Wu AW, Thamboo AV, Higgins TS, Scangas GA, Oliveira K, Ho AS, Mallen-St Clair J, Walgama E. A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing. Otolaryngol Head Neck Surg 2021; 165:647-654. [PMID: 33588621 DOI: 10.1177/0194599820988740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed. STUDY DESIGN A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given. SETTING Patients with nonabsorbable nasal packing placed. METHODS Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model. RESULTS The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective. CONCLUSIONS Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence. LEVEL OF EVIDENCE 3a.
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Affiliation(s)
- Ximena Maul
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Otolaryngology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Berkay C Dincer
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA.,School of Medicine, Hacettepe University, Ankara, Turkey
| | - Arthur W Wu
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA
| | - Andrew V Thamboo
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas S Higgins
- Department of Otolaryngology-Head and Neck, University of Louisville, Louisville, Kentucky, USA
| | - George A Scangas
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Kristin Oliveira
- Department of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut, USA
| | - Allen S Ho
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA
| | - Jon Mallen-St Clair
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, California, USA
| | - Evan Walgama
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Nguyen A, Ho A, Luu M, Mita A, Scher K, Lu D, Mallen-St. Clair J, Walgama E, Zumsteg Z. Re-examining the Changes in the Pathologic Nodal Classification Systems for HPV(+) and HPV(-) Oropharyngeal Cancer. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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8
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Ho AS, Luu M, Barrios L, Balzer BL, Bose S, Fan X, Walgama E, Mallen-St Clair J, Alam U, Shafqat I, Lin DC, Chen Y, Van Eyk JE, Maghami EG, Braunstein GD, Sacks WL, Zumsteg ZS. Prognostic Impact of Histologic Grade for Papillary Thyroid Carcinoma. Ann Surg Oncol 2020; 28:1731-1739. [PMID: 32808161 DOI: 10.1245/s10434-020-09023-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND While numerous factors affect prognosis in papillary thyroid carcinoma (PTC), the comparative impact of histologic grade has not been well described. Moreover, indications for external beam radiation therapy (EBRT) remain imprecise. We evaluate clinicopathologic characteristics and outcomes for PTC stratified by grade. METHODS We profiled histologic grade for PTC (well differentiated, moderately differentiated, poorly differentiated) via hospital (National Cancer Database) and population-based (Surveillance, Epidemiology, and End Results) registries. Cox regression was used to adjust for clinicopathologic covariates. Statistical interactions between subtypes and the effect of EBRT on survival were assessed. RESULTS Collectively, worsening clinicopathologic factors (age, tumor size, extrathyroidal extension, nodal spread, M1 disease) and outcomes (disease-free survival, overall survival) correlated with less differentiated state, across all histologic grades (p < 0.001). Multivariable analysis showed escalating hazard with loss of differentiation relative to well-differentiated PTC (moderately differentiated hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.04-1.41, p = 0.02; poorly differentiated HR 2.62, 95% CI 2.23-3.08, p < 0.001). Correspondingly, greater survival benefit was associated with EBRT for poorly differentiated cases (HR 0.36, 95% CI 0.18-0.72, p = 0.004). This finding was upheld after landmark analysis to address potential immortal time bias (HR 0.37, 95% CI 0.17-0.80, p = 0.01). CONCLUSIONS Worsening histologic grade in PTC is independently associated with parallel escalation in mortality risk, on a scale approximating or surpassing established thyroid cancer risk factors. On preliminary analysis, EBRT was associated with improved survival in the most aggressive or least differentiated subvariants. Further investigation is warranted to examine the efficacy of EBRT for select poorly differentiated thyroid carcinomas.
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Affiliation(s)
- Allen S Ho
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Michael Luu
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Biostatistics and Bioinformatics Research Center, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Laurel Barrios
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bonnie L Balzer
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shikha Bose
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Xuemo Fan
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Evan Walgama
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon Mallen-St Clair
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Usman Alam
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Iram Shafqat
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - De-Chen Lin
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yufei Chen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer E Van Eyk
- Advanced Clinical Biosystems Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ellie G Maghami
- Division of Head and Neck Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Glenn D Braunstein
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Wendy L Sacks
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zachary S Zumsteg
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Ayoub N, Walgama E, Thamboo A, Chitsuthipakorn W, Patel ZM, Nayak JV, Hwang PH. Correlation between extent of sinus surgery, radiographic disease, and postoperative outcomes. Rhinology 2020; 58:36-44. [PMID: 31671433 DOI: 10.4193/rhin19.213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The extent of endoscopic sinus surgery (ESS) required for optimal outcomes in chronic rhinosinusitis (CRS) is undefined. We evaluated whether concordance between the extent of surgery and degree of radiographic disease influences postoperative outcomes. METHODS 247 CRS patients who underwent ESS were retrospectively assigned a concordance score reflecting the similarity between the extent of surgery and degree of radiographic disease. 0 points were assigned when sinusotomy was performed on a diseased sinus, or no sinusotomy was performed on a nondiseased sinus; plus 1 for sinusotomy on a nondiseased sinus; and -1 for a diseased sinus left unopened. The total possible score ranged from minus 10 to plus 10. Patients were divided into 5 subgroups according to variance from complete concordance. SNOT-22 scores and revision rates were compared at 6 and 24 months. RESULTS All five subgroups had similar preoperative SNOT-22 scores and improved at 6 months postoperatively. At 6 months postoperatively, the most conservatively operated and most extensively operated subgroups each achieved equivalent improvements in SNOT-22 as the completely concordant subgroup. At 24 months, the most extensively operated subgroup had a 12.5-point smaller improvement in SNOT-22 scores compared to the completely concordant subgroup. Multivariate analysis showed no association between concordance score and revision rate. CONCLUSIONS Symptom improvement and revision rates after ESS do not appear to correlate with the degree of concordance between extent of surgery and radiographic disease. More extensive surgery than indicated by CT confers neither greater symptomatic improvement nor long-term detriment.
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Affiliation(s)
- N Ayoub
- Department of Otolaryngology â€" Head and Neck Surgery, Stanford University, Palo Alto, CA, United States
| | - E Walgama
- Department of Otolaryngology â€" Head and Neck Surgery, Stanford University, Palo Alto, CA, United States; Department of Otolaryngology â€" Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - A Thamboo
- Department of Otolaryngology â€" Head and Neck Surgery, Stanford University, Palo Alto, CA, United States; Department of Otolaryngology â€" Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - W Chitsuthipakorn
- Center of Excellence in Otolaryngology, Head and Neck Surgery. Rajavithi Hospital, Rangsit University. Bangkok, Thailand
| | - Z M Patel
- Department of Otolaryngology â€" Head and Neck Surgery, Stanford University, Palo Alto, CA, United States
| | - J V Nayak
- Department of Otolaryngology â€" Head and Neck Surgery, Stanford University, Palo Alto, CA, United States
| | - P H Hwang
- Department of Otolaryngology â€" Head and Neck Surgery, Stanford University, Palo Alto, CA, United States
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10
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Walgama E, Randolph GW, Lewis C, Tolley N, Sacks W, Chen Y, Ho AS. Cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for low-risk thyroid cancer patients. Head Neck 2020; 42:2593-2601. [PMID: 32510729 DOI: 10.1002/hed.26312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/24/2020] [Accepted: 05/15/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Flexible fiberoptic laryngoscopy is performed prior to thyroid surgery to evaluate the function of the recurrent laryngeal nerve. We assess the cost-effectiveness of preoperative laryngoscopy prior to total thyroidectomy for a low-risk thyroid cancer patient without dysphonia. METHODS A decision tree analysis was performed from a third-party payer perspective. We assessed the cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for T2N0M0 papillary thyroid carcinoma, such that an ipsilateral vocal fold paralysis alters the surgical plan to hemi-thyroidectomy, when permissible, to avoid the risk of bilateral vocal fold paralysis. RESULTS Performing preoperative laryngoscopy to assess vocal fold function has an incremental cost-effectiveness ratio (ICER) of 45 193 USD/QALY compared to no laryngoscopy. At a willingness-to-pay of 100 K/QALY, the intervention is cost-effective if the incidence of vocal fold paralysis is at least 0.57%, or when the permissible rate of hemithyroidectomy in cases of incidental paralysis is at least 41%. Probabilistic sensitivity analysis shows that laryngoscopy is cost-effective in 90.9% of cases. CONCLUSIONS Fiberoptic laryngoscopy is a cost-effective prior to total thyroidectomy in asymptomatic, low-risk thyroid cancer patients.
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Affiliation(s)
- Evan Walgama
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.,Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carol Lewis
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Neil Tolley
- Department of Otorhinolaryngology and Head & Neck Surgery, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Wendy Sacks
- Department of Medicine, Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yufei Chen
- Department of Surgery, Division of Endocrine Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Allen S Ho
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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11
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Walgama E, Sinclair C, Chen AY, Davies L, Noel JE, Orloff LA, Shindo M, Sigston E, Stack BC, Terris D, Randolph GW. Re: "Routine Preoperative Laryngoscopy for Thyroid Surgery Is Not Necessary Without Risk Factors" by Maher et al. (Thyroid 2019;29:1646-1652. DOI: 10.1089/thy.2019.0145). Thyroid 2020; 30:785-786. [PMID: 32228150 DOI: 10.1089/thy.2020.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Evan Walgama
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Catherine Sinclair
- Department of Ear, Nose, and Throat-Head and Neck Surgery, Mount Sinai Health System, New York, New York, USA
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Louise Davies
- Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Julia E Noel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Lisa A Orloff
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Maisie Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Elizabeth Sigston
- Department of Otorhinolaryngology, Head and Neck Surgery, Monash Health, Melbourne, Australia
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - David Terris
- Department of Otolaryngology, Augusta University, Augusta, Georgia, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Scangas GA, Wu AW, Ting JY, Metson R, Walgama E, Shrime MG, Higgins TS. Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps. Laryngoscope 2020; 131:E26-E33. [PMID: 32243622 DOI: 10.1002/lary.28648] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/11/2020] [Accepted: 03/05/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP. STUDY DESIGN Cohort-style Markov decision-tree economic model with a 36-year time horizon. METHODS A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed. RESULTS The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855. CONCLUSIONS The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner. LEVEL OF EVIDENCE 2C Laryngoscope, 131:E26-E33, 2021.
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Affiliation(s)
- George A Scangas
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Arthur W Wu
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Jonathan Y Ting
- Department of Otolaryngology, Indiana University, Indianapolis, Indiana, U.S.A
| | - Ralph Metson
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Evan Walgama
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Mark G Shrime
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
- Center for Global Surgery Evaluation, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Thomas S Higgins
- Department of Otolaryngology, University of Louisville School of Medicine, Louisville, Kentucky, U.S.A
- Rhinology, Sinus & Skull Base, Kentuckiana Ear, Nose & Throat, Louisville, Kentucky, U.S.A
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Lee SJ, Cohen J, Chan J, Walgama E, Wu A, Mamelak AN. Infectious Complications of Expanded Endoscopic Transsphenoidal Surgery: A Retrospective Cohort Analysis of 100 Cases. J Neurol Surg B Skull Base 2019; 81:497-504. [PMID: 33134016 DOI: 10.1055/s-0039-1696999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/08/2019] [Indexed: 12/14/2022] Open
Abstract
Objective To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS). Study Design This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis. Results A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33-56.47; p = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected. Conclusion CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.
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Affiliation(s)
- Seung J Lee
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Justin Cohen
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Julie Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Evan Walgama
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Arthur Wu
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
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Affiliation(s)
- Jonathan Choi
- Department of Otolaryngology-Head and Neck Surgery and Comprehensive Skull Base Program, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Nayak JV, Rathor A, Grayson JW, Bravo DT, Velasquez N, Noel J, Beswick DM, Riley KO, Patel ZM, Cho DY, Dodd RL, Thamboo A, Choby GW, Walgama E, Harsh GR, Hwang PH, Clemons L, Lowman D, Richman JS, Woodworth BA. Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling. Int Forum Allergy Rhinol 2018; 8:1162-1168. [PMID: 29856526 DOI: 10.1002/alr.22156] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing. METHODS In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases. RESULTS Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion. CONCLUSION This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.
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Affiliation(s)
- Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Aakanksha Rathor
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jessica W Grayson
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Dawn T Bravo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Nathalia Velasquez
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Julia Noel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Daniel M Beswick
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama Birmingham, Birmingham, AL
| | - Zara M Patel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Do-Yeon Cho
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Robert L Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Andrew Thamboo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Garret W Choby
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Evan Walgama
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Griffith R Harsh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Lisa Clemons
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Deborah Lowman
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Joshua S Richman
- Department of Neurosurgery, University of Alabama Birmingham, Birmingham, AL
| | - Bradford A Woodworth
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
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Patel VS, Walgama E, Psaltis A, Lavigne F, Pletcher SD, Hwang PH. Biocompatibility and Pharmacokinetics of Fluticasone-Eluting Sinus Implant in a Rabbit Model. Am J Rhinol Allergy 2017; 31:382-388. [DOI: 10.2500/ajra.2017.31.4481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background A novel, bioabsorbable, fibrinogen-based implant has been developed as a mucosal dressing after endoscopic sinus surgery (ESS). This implant can be formulated with fluticasone propionate (TP) for local elution of corticosteroid to reduce postoperative inflammation and promote mucosal healing. Objective This study investigated the biocompatibility and pharmacokinetics of the implant in a rabbit model. Methods Implants with and without TP were placed on both intact and demucosalized maxillary sinuses of 33 New Zealand White rabbits. Sinuses with either intact or denuded bone without implants acted as controls. Histopathologic assessments were carried out at 5, 15, and 28 days. Concentrations of TP in the maxillary sinus mucosa, nasal cavity mucosa, and plasma were measured for up to 44 days. Results Implants placed on intact mucosa or denuded bone were grossly integrated within 15 days. Minimal foreign body reaction was seen with negligible differences for inflammation, fibrosis, or bone remodeling among controls, sinuses with the implant, or sinuses with the implant plus TP, at all time points. All samples also showed complete or near-complete percentage reepithelialization at 28 days, although the denuded bone controls demonstrated greater percentage reepithelialization at 5 days compared with denuded bone with the implant or implant plus TP (p <0.0001). The maxillary sinus mucosa demonstrated levels of TP of >140 ng/g up to 44 days. Plasma concentrations of TP were generally very low and were undetectable after day 7. Conclusions The implant and the implant plus TP seemed to be biocompatible in rabbits. The implant plus TP effectively eluted steroid locally over at least 44 days, with negligible plasma concentrations. Further studies are warranted regarding potential therapeutic applications in patients undergoing ESS for chronic rhinosinusitis.
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Affiliation(s)
- Vishal S. Patel
- Department of Otolaryngology—Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Evan Walgama
- Department of Otolaryngology—Head and Neck Surgery, Cedars-Sinai, Los Angeles, California
| | - Alkis Psaltis
- Department of Otolaryngology—Head and Neck Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - Francois Lavigne
- Department of Otolaryngology—Head and Neck Surgery, Université de Montreal, Montreal, Quebec, Canada
| | - Steven D. Pletcher
- Department of Otolaryngology—Head and Neck Surgery, University of California, San Francisco, San Francisco, California Presented at the American Rhinologic Society Spring Meeting, San Diego, CA
| | - Peter H. Hwang
- Department of Otolaryngology—Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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Ayoub N, Walgama E, Thamboo A, Nayak JV, Hwang PH. Efficacy of endoscopic sinus surgery for chronic rhinosinusitis following primary radiotherapy and concurrent chemotherapy for nasopharyngeal carcinoma. Int Forum Allergy Rhinol 2017; 7:1045-1051. [DOI: 10.1002/alr.22002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/22/2017] [Accepted: 07/26/2017] [Indexed: 01/24/2023]
Affiliation(s)
- Noel Ayoub
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery; Stanford University School of Medicine; Stanford CA
| | - Evan Walgama
- Division of Otolaryngology, Department of General Surgery; Cedars Sinai Medical Center; Los Angeles CA
| | - Andrew Thamboo
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery; Stanford University School of Medicine; Stanford CA
| | - Jayakar V. Nayak
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery; Stanford University School of Medicine; Stanford CA
| | - Peter H. Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery; Stanford University School of Medicine; Stanford CA
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Locketz GD, Teo NW, Walgama E, Humphreys IM, Nayak JV. The nasal vestibular body: anatomy, clinical features, and treatment considerations. Eur Arch Otorhinolaryngol 2016; 273:777-81. [PMID: 26825801 DOI: 10.1007/s00405-015-3868-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
Abstract
Nasal obstruction is a common presenting complaint, with many possible etiologies. Herein, we provide an introductory anatomic description, clinical relevance, and proposed nomenclature for an underappreciated soft tissue focus in the nasal vestibule-the nasal vestibular body (NVB)-that can contribute to nasal obstruction in a subset of patients. This is a small mound of dynamic soft tissue in the lateral aspect of the internal nasal valve, situated inferior and anterior to the head of the inferior turbinate that can be missed on routine examination for many salient reasons. In well-selected patients, whose symptoms of nasal obstruction may in part be secondary to the presence of this soft tissue focus, directed testing and tissue reduction can be performed.
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Affiliation(s)
- Garrett D Locketz
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, 801 Welch Road, Stanford, CA, 94305, USA
| | - Neville W Teo
- Department of Otolaryngology, Singapore General Hospital, Singapore, Singapore
| | - Evan Walgama
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, 801 Welch Road, Stanford, CA, 94305, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head & Neck Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Jayakar V Nayak
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, 801 Welch Road, Stanford, CA, 94305, USA.
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Clark C, Walgama E, Ryan MW. Massive Sinonasal Polyposis. JAMA Otolaryngol Head Neck Surg 2015; 141:669-70. [PMID: 25996681 DOI: 10.1001/jamaoto.2015.0798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christopher Clark
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Evan Walgama
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Matthew W Ryan
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas
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Walgama E, Ulualp SO, Koral K. Intraoral mass causing obstructive sleep apnea. Venolymphatic malformation of the soft palate. JAMA Otolaryngol Head Neck Surg 2013; 139:1075-6. [PMID: 23989390 DOI: 10.1001/jamaoto.2013.4417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Walgama E, Thanasumpun T, Gander R, Batra PS. Comparison of endoscopically-guided swab vs aspirate culture techniques in post-endoscopic sinus surgery patients: blinded, prospective analysis. Int Forum Allergy Rhinol 2013; 3:726-30. [DOI: 10.1002/alr.21170] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 02/07/2013] [Accepted: 02/26/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Evan Walgama
- Department of Otolaryngology-Head and Neck Surgery; University of Texas Southwestern Medical Center; Dallas TX
| | - Thunchai Thanasumpun
- Department of Otolaryngology-Head and Neck Surgery; Faculty of Medicine Vajira Hospital; Bangkok Thailand
| | - Rita Gander
- Department of Pathology; University of Texas Southwestern Medical Center; Dallas TX
| | - Pete S. Batra
- Department of Otolaryngology-Head and Neck Surgery; University of Texas Southwestern Medical Center; Dallas TX
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Walgama E, Ahn C, Batra PS. Surgical management of frontal sinus inverted papilloma: a systematic review. Laryngoscope 2012; 122:1205-9. [PMID: 22460718 DOI: 10.1002/lary.23275] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 01/24/2012] [Accepted: 02/07/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Surgical management of frontal sinus (FS) inverted papilloma (IP) remains a significant challenge. This study systematically reviews the FS IP literature to delineate outcomes based on surgical strategy. STUDY DESIGN Systematic review. METHODS Cases for inclusion were identified by literature query for the terms frontal sinus and inverted papilloma between 1995 and 2010. Cases reported with sufficient outcomes data, defined as specific surgical approach and disease-free follow-up, were included. Statistical analysis was performed to identify significant risk factors for recurrence. The reported length of follow-up for each surgical approach was analyzed as an indicator of the strength of the reported literature for each approach. RESULTS Fifty-seven cases were identified in 13 studies, with 49 cases deemed adequate for additional analysis. Twenty-four cases (49%) were primary, and 25 (51%) were secondary (residual or recurrent disease) IP. Bilateral FS involvement was reported in eight cases (16.3%). Surgical approaches employed included endoscopic frontal sinusotomy (EFS) in 21 (42.9%), endoscopic modified Lothrop (EML) in 10 (20.4%), osteoplastic flap in 13 (26.5%), and endoscopic trephination and EFS in five (10.2%) patients. The overall rate of recurrence was 22.4%. Mean follow-up time was 27 months. CONCLUSIONS The recent reported literature of FS IP demonstrates high prevalence of recurrent and bilateral cases. Although statistical analysis of this accrued data is unable to delineate the best surgical approach for FS IP, more aggressive approaches frequently employed for secondary or bilateral disease may facilitate better disease control.
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Affiliation(s)
- Evan Walgama
- Department of Otolaryngology-Head and Neck Surgery and Comprehensive Skull Base Program, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
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Farkas JP, Richardson JA, Brown SA, Ticker B, Walgama E, Burrus CF, Hoopman JE, Barton FE, Kenkel JM. TUNEL assay to characterize acute histopathological injury following treatment with the active and deep FX fractional short-pulse CO2 devices. Aesthet Surg J 2010; 30:603-13. [PMID: 20829258 DOI: 10.1177/1090820x10380547] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo. METHODS The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation. RESULTS The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column. CONCLUSIONS The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.
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Affiliation(s)
- Jordan P Farkas
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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