55 annual meeting - american rhinologic · inadequate health insurance cost cov-erage a major...

55th

annual meetingof the American Rhinologic Society

October 3, 2009Manchester Grand Hyatt, One Market Place, San Diego, CA

3

PROGRAM AT-A-GLANCEOctober 3, 20097:00 AMBreakfast SymposiumPoint of Service in RhinologyModerator: Brent A. Senior, M.D.

8:00 AMWelcome & Opening RemarksJames Stankiewicz, MD - President

Moderators: Karen Fong, M.D./Rick Chandra, M.D.8:07 AMTNF-Alpha Inhibits OlfactoryRegeneration in a Transgenic Model ofChronic Rhinosinusitis-AsssociatedOlfactory LossJustin Turner, M.D.

8:13 AMThe Efficacy of a Novel Chitosan Gelon Hemostasis and Wound HealingFollowing Endoscopic Sinus SurgeryRowan Valentine, M.D.

8:19 AMEfficacy of an Antibiotic ElutingChitosan Glycerophosphate Implant inthe Setting of Acute Bacterial Sinusitis:A Rabbit ModelBenjamin Bleier, M.D.

8:25 AMDiscussion and Q&A

Moderators: Robert Kern, M.D/James Palmer, M.D.8:35 AMCharacterisation of Bacterial andFungal Biofilms in ChronicRhinosinusitisAndrew Foreman, M.D.

8:41 AMActivation of Ciliary Beat Frequency inPrimary Murine Nasal EpithelialCultures by the CFTR Potentiator,QuercetinBradford Woodworth, M.D.

8:47 AMThe Role of Hepatocyte GrowthFactor/C-met in Chronic Rhinosinusitiswith PolypsMurugappan Ramanathan, M.D.

8:53 PMDiscussion and Q&A

9:03 AMPresidential AddressJames Stankiewicz, MD

Moderators: Alexander Chiu, M.D./Brent Senior, M.D.9:10 AMDecreased Regulatory T-cells inSinonasal Mucosa and Circulatingblood in Patients with ChronicRhinosinusitis with Nasal PolyposisAmanda Munoz, M.D.

9:16 AMPost Surgical Outcomes of EndoscopicSinus Surgery, Done for ChronicRhinosinusitis Associated with BiofilmsDeepti Singhal, M.D.

9:22 AMHoney: Histological Effect onRespiratory MucosaShaun Kilty, M.D.


Moderator: Richard Orlandi, M.D.9:38 AMMasters in Rhinology - How I Do It:Skull Base Tumors-Tips and TechniqueRoy Casiano, M.D.

9:53 AMDiscussion

9:59 AMBreak with Exhibitors (Manchester D-I)

Moderators: Rodney Schlosser,M.D./ Roy Casiano, M.D.10:20 AMPerioperative ContinuousCerebrospinal Fluid PressureMonitoring in Patients withSpontaneous Cerebrospinal FluidLeaks: Presentation of a NovelTechniqueDouglas Reh, M.D.

4

10:26 AMPost-operative Healing in EndoscopicRepair of Skull Base Defects: AComparison of Three Graft MaterialsKara Prickett, M.D.

10:32 AMEndoscopic Intracranial Resection:Case Series and Design andEmployment of a PerioperativeManagement ProtocolEvan Ransom, M.D.


Moderators: Berrylin J Ferguson, M.D.10:48 AMOrbital Involvement in Invasive FungalSinusitis: Review of Outcomes andRecommendation of a TreatmentParadigmLindsey Arviso, M.D.

10:54 AMIncreased Prevalence ofStaphylococcus aureus in AllergicFungal Rhinosinusitis Versus OtherSubsets of Chronic Rhinosinusitis withNasal PolypsDavid Clark, M.D.

11:00 AMUpdate to Severity Classification forChronic RhinosinusitisTroy Woodard, M.D.


11:16 AMModerator: Joseph Jacobs, M.D.Managing Refractory Sinusitis Surgicaland Medical Considerations Panel

Panelists:Michael Chandler, M.D.Clinical Assistant Professor of Medicine, TheMount Sinai School of MedicineNew York, NY

Martin Desrosiers, MD, FRCSCClinical Associate ProfessorDepartment of Otolaryngoglogy-Head andNeck Surgery; Université de Montréal andMcGill Universities; Montréal, Quebec,Canada

Amber Luong, MD, PhDAssistant Professor of Otorhinolaryngology-Head and Neck Surgery: University of TexasHealth Science Center at Houston; Assistant

Professor of Immunology at UT MDAnderson Cancer Center

12:00 PMBusiness Meeting/Award Presentation

12:00 PMBreak with Exhibitors (Manchester D-I)

Moderators: Neil Bhattacharyya, M.D./Timothy Smith, M.D.1:00 PMPresence of Dendritic Cells Expressingpro-Th2 Costimulatory Molecules isIncreased in Patients with AllergicFungal Sinusitis and ChronicRhinosinusitis Without Nasal PolypsBrendan O'Connell

1:06 PMTargeting TGF-beta 1 ReceptorsModulates Adherent Junctions inChronic Rhinosinusitis (CRS)Ramin Naim, M.D.

1:12 PMEffect of Dilute Baby Shampoo onNasal Mucociliary Clearance in HealthySubjectsSeth Isaacs, M.D.


Moderators: John DelGaudio, M.D./Patricia Maeso, M.D.1:28 PMEndonasal Laser Tissue Welding: FirstHuman ExperienceBenjamin Bleier, M.D.

1:34 PMFracture of Bony Lamellae Within theFrontal Recess Following BalloonCatheter DilatationAyesha Khalid, M.D.

1:40 PMCharacterizing Methicillin-ResistantStaphylococcus Aureus Infections in aTertiary Rhinology PracticeVictoria Epstein, M.D.


Moderators: Joseph Jacobs, M.D. /Marvin Fried, M.D.1:56 PMPost Sinus Surgery Nasal Irrigation:

5

What are the Real Risks ofContamination?John Lee, M.D.

2:02 PMEndoscopic Sinus Surgery in the AdultCystic Fibrosis Patient: Effect on LungFunction, Intravenous Antibiotic Use,and HospitalizationOswaldo Henriquez, M.D.

2:08 PMSafety, Feasibility, and Tolerability of In-office Balloon Sinus DilationFord Albritton, IV, M.D.


Moderator: Stilianos Kountakis, M.D.2:24 PM5th Annual David W. KennedyLectureship The Frontal SinusPeter John Wormald, M.D.

2:50 PMBreak with Exhibitors (Manchester D-I)

Moderators: Troy Woodard, M.D./ Todd Kingdom, M.D.3:10 PMNicotine Induces Resistance toChemotherapy in NasophayngealCancersTianjie Shen, M.D.

3:16 PMVideo-Based Assessment of OperativeCompetency in Endoscopic SinusSurgery (ESS)Kulsoom Laeeq, M.D.

3:22 PMSafety and Effectiveness of BalloonCatheter Sinus Ostia Dilation in thePediatric Population: A Multicenter 52week Analysis.Hassan Ramadan, M.D.


Moderators: Peter Hwang, M.D./Martin Citardi, M.D.3:38 PMEndoscopic Coblator-AssistedManagement of Encephaloceles: AProspective StudyNicholas Smith, M.D.

3:44 PMEndoscopic Anterior Skull BaseSurgery: Intra-OperativeConsiderations of the Crista Galli andPost-Operative OutcomesJohn Lee, M.D.

3:50 PMSpontaneous CSF Leaks: DelineatingPredictive Factors for SuccessRahul Seth, M.D


Moderators: Hassan Ramadan, M.D./Peter Catalano, M.D.4:06 PMRadiographic Examination of AnatomicRelationships of the Posterior EthmoidArteryOswaldo Henriquez, M.D.

4:12 PMTopical Epinephrine is Safe inEndoscopic Sinus SurgeryRichard Orlandi, M.D.

4:18 PMThe Role of StenotrophomonasMaltophilia in Refractory ChronicRhinosinusitisDavid Grindler, M.D.


Moderator: Michael Setzen, M.D.4:34 PMMasters in Rhinology - How I Do It:Endoscopic Modified LothropProcedure, Tips and TechniquesPeter John Wormald, M.D.

Posters:Characterization of Bacterial Microbiotain Post-Surgical Maxillary Sinus ofChronic Rhinosinusitis (CRS) PatientsUsing Molecular 16S rRNA Gene-Based AnalysesCindy Liu, M.D.

Complementary and AlternativeMedicine for Chronic Rhinosinusitis: AReview of the LiteratureRajanya Petersson, M.D.

6

Computed Tomography Evaluation ofNasal Valve Changes with 2- and 3-mmSpreader GraftsDavid Archibald, M.D.

Controversies in Management ofIntracranial Angiofibroma: A LiteratureReview and Personal ExperienceMohsen Naraghi, M.D.

Ectopic Pituitary Adenoma withApoplexy Presenting as Clival MassPamela Mudd, M.D.

Endoscopic Resection of SchneiderianPapillomas with Inferior TurbinatePreservationKimberley Rutherford, M.D.

Endoscopic Sphenoid Balloon SinuplastyB. Todd Schaeffer, M.D.

Extended Inferior Turbinate Reductionin the Narrow NoseAndrew Lerrick, M.D.

Gender and the Presentation of ChronicRhinosinusitisDavid Lin, M.D.

Glomangioma of the Nasal SeptumDaniel Monin, M.D.

Inadequate health insurance cost cov-erage a major factor in discontinuationof subcutaneous immunotherapy forAllergic RhinitisRavi Surender Vaswani, M.D., Yi-ChunCarol Liu, M.D., Leena Parikh, M.D.

Local Nasal Immunotherapy ForAllergic Rhinitis: A Systematic ReviewStephen McDonald, FRCS

Management of Sinusitis and GraftPreservation After Sinus Lift ProcedureAshutosh Kacker, M.D.

Massive Cerebral Infarction afterEmbolization for NasopharyngealAngiofibromaMohsen Naraghi, M.D.

Maxillary Pneumocele: A CasePresentation With ProgressiveSymptomsMohsen Naraghi, M.D.

Modulation of Ambient Air Pollution-Induced Nasal Epithelial Inflammation byProtein Kinase C- subtype in HumansDo-Yeon Cho, M.D.

Olfactory Dysfunction in Allergic FungalSinusitisCarl Philpott, M.D.

Orbital Extension of NasopharyngealAngiofibromaMohsen Naraghi, M.D.

Perioperative Continuous CerebrospinalFluid Pressure Monitoring in Patientswith Spontaneous Cerebrospinal Fluidleaks: Presentation of a Novel TechniqueDouglas Reh, M.D.

Positive Fungal Cultures in Allergic andNon-Allergic Fungal SinusitisChristopher Melroy, M.D.

Practical Reduction of the Bulky InferiorTurbinateAndrew Lerrick, M.D.

Role of Radiographic Imaging in thePreoperative Evaluation of AdultsUndergoing Septoplasty for NasalObstructionBruce Tan, M.D

Spontaneous CSF Fistula withEncephalocele Presenting as SevereObstructive Sleep ApneaSivakumar Chinnadurai, M.D.

Surgical Anatomy of the SphenoidSinus, Internal Carotid Artery andDistances to Critical StructuresStephanie Joe, M.D.

Unilateral Epistaxis in a Middle AgedMan: A Rare Presentation of PyogenicGranulomaJason Champagne, M.D.

Unrecognized Odontogenic MaxillarySinusitis - A Cause of EndoscopicSinus Surgery FailureAnthony Longhini, BS

Zygomaticomaxillary Mucocele withConcomitant Frontoethmoid MucocelePresenting Four Decades after FacialTraumaBenjamin Powell, M.D.

Officers

8

James Stankiewicz, MDPresidentLoyola UniversityDepartment of Otolaryngology2160 South First AvenueMaywood, IL 60153Tel: 708-216-8527, Fax: 708-216-4834Email: [email protected]

Stilianos Kountakis, MDPresident-ElectMedical College of Georgia1120 15th StreetSuite BP-4109Augusta, GA 30912Tel: 706-721-6100, Fax: 706-721-0112Email: [email protected]

Peter Hwang, MDSecretary801 Welch RoadStanford, CA 94305Tel: 650-725-6500, Fax: 650-725-8502Email: [email protected]

Joseph B. Jacobs, MDTreasurerNYU Medical Center530 First Avenue, Suite CNew York, NY 10016Tel: 212-263-7398, Fax: 212-263-8490Email: [email protected]

Brent A. Senior, MDFirst Vice PresidentUniversity of North CarolinaDepartment of Otolaryngology - Physician Building170 Manning Drive, CB 7070Chapel Hill, NC 27955Tel: 919-966-3342, Fax: 919-966-7941Email: [email protected]

9

Michael Setzen, MDSecond Vice President600 Northern Blvd., Suite 312Great Neck, NY 11021Tel: 516-829-0045, Fax: 516-829-0441Email: [email protected]

Marvin P. Fried, MDImmediate Past PresidentMontefiore Medical Center3400 Bainbridge Avenue, MAP 3rd fl.Bronx, NY 10467Tel: 718-920-2991, Fax: 718-882-2463Email: [email protected]

Howard L. Levine, MDPast PresidentCleveland Nasal, Sinus & Sleep5555 Transportation Blvd., Suite CCleveland, OH 44125Tel: 216-518-3298, Fax: 216-518-3297Email: [email protected]

Wendi PerezAdministratorPO Box 495Warwick, NY 10990Tel: 845-988-1631, Fax: 845-986-1527Email: [email protected]

10

Board of Directors

Consultants to the Board

Karen Fong, MDSan Ramon, CA

Bradley Marple, MDDallas, TX

Timothy Smith, MDPortland, OR

Michael Setzen, MDManhasset, NY

Todd Kingdom, MDAurora, CO

Kathleen Yaremchuk, MDDetroit, MI

Peter Catalano, MDBurlington, MA

Paul Toffel, MDGlendale, CA

Robert Kern, MDChicago, IL

Neil Bhattacharyya, MDBoston, MA

11

Chairs

Audit Roy Casiano, MD

By-Laws & Research GrantsAndrew Lane, MD

AwardsTimothy Smith, MD

Business RelationsJoseph Jacobs, MD

CMEJames Palmer, MD

Corporate LiaisonPaul Toffel, MD

CredentialsJohn Delgaudio, MD

Education/FellowshipProgram

Todd Kingdom, MD

EthicsKevin McMains, MD

Information TechnologyJay Dutton, MD

International LiaisonJan Gospath, MD

MembershipStephanie Joe, MD

Patient AdvocacyPete Batra, MD

Pediatric RhinologySanjay Parikh, MD

Resident/FellowsSeth Brown, MD

NewsletterRakesh Chandra, MD

13

Past Presidents/Secretaries

14

1954 - 1955 Maurice H. Cottle, MD*1955 - 1956 Ralph H. Riggs, MD*1956 - 1957 Walter E. E. Loch, MD*1958 - 1959 Kenneth H. Hinderer, MD*1959 - 1960 Roland M. Loring, MD*1960 - 1961 Ivan W. Philpott, MD*1962 - 1963 Raymond I. Hilsinger, MD*1963 - 1964 H. Ashton Thomas, MD*1964 - 1965 Carl B. Sputh, MD1966 - 1967 Walter J. Aagesen, MD1967 - 1968 Richard Hadley, MD*1968 - 1969 Henry L. Williams, MD*1970 - 1971 Charles A. Tucker, MD*1971 - 1972 Pat A. Barelli, MD1972 - 1973 Gerald F. Joseph, MD1973 - 1974 Manuel R. Wexler, MD*1974 - 1975 George H. Drumheiler, MD*1975 - 1976 Joseph W. West, MD*1976 - 1977 Albert Steiner, MD*1977 - 1978 Anthony Failla, MD*1978 - 1979 Clifford F. Lake, MD*1979 - 1980 W. K. Locklin, MD1981 - 1982 Eugene B. Kern, MD1982 - 1983 Carlos G. Benavides, MD1983 - 1984 Leon Neiman, MD1984 - 1985 George C. Facer, MD1985 - 1986 Larry E. Duberstein, MD1986 - 1987 Glenn W. Drumheiler, DO1987 - 1988 Alvin Katz, MD1988 - 1989 Donald Leopold, MD1990 - 1991 Pierre Arbour, MD1991 - 1992 Fred Stucker, MD1992 - 1993 David W. Kennedy, MD1993 - 1994 Sanford R. Hoffman, MD1994 - 1995 Richard J. Trevino, MD1995 - 1996 Vijay K. Anand, MD1996 - 1997 Dale H. Rice, MD1997 - 1998 Michael S. Benninger, MD1998 - 1999 William Panje, MD1999 - 2000 Charles W. Gross, MD2000 - 2001 Frederick A. Kuhn, MD2001 - 2002 Paul Toffel, MD2002 - 2003 Donald C. Lanza, MD2003 - 2004 James A. Hadley, MD2004 - 2005 Joseph B. Jacobs, MD2005 - 2006 Michael J. Sillers, MD2006 - 2007 Howard L. Levine, MD2007 - 2008 Marvin P. Fried, MD2008 - 2009 James Stankiewicz, MD

*Deceased

Past Presidents PastSecretaries2005-2008Brent A. Senior, MD

1999 - 2005Marvin P. Fried, MD

1995 - 1999Frederick Stucker, MD

1990-1995Frank Lucente, MD

1985-1990George Facer, MD

1980 - 1985Pat A. Barelli, MD

1975 - 1980Glenn H. Drumhiller, MD

1970 - 1975Ralph H. Riggs, MD

Business/ACCME

16

ARS Mission Statement

The American Rhinologic Society’s mission is to serve,

represent and advance the science and ethical practice of

rhinology. The Society promotes excellence in patient care,

research and education in Rhinology and Skull Base

Disorders. The American Rhinologic Society is dedicated

to providing communication and fellowship to the members

of the Rhinologic community through on-going medical

education, patient advocacy, and social programs. The

ARS continuing medical education activities serve to

improve professional competence, performance, and

promote research.

17

Educational ObjectivesThis activity will consist of presentations from abstracts selectedby the program committee through a blinded review process.Panel discussions will be held based on prior participantfeedback. The specific objectives are as follows:1 Discuss the newest cutting edge information on the medical

management of patients with rhinosinusitis and skull base lesions.

2 List the newest techniques in the surgical management of patients with rhinosinusitis.

3 Cite current research in the pathogenesis and pathophysiology of chronic rhinosinusitis.

4 Describe the surgical techniques used to reconstruct skull base defects.

5 Discuss how to manage patients with olfactory disorders.

GoalThe goal of this activity is to improve competence surgically andmedically and to greater the knowledge of techniques,outcomes and basic science.

Outcomes1. The practitioner should be able to choose appropriate therapy

for the different subtypes of chronic rhinosinusitis.2. The practitioner should be able to incorporate surgical

techniques to manage patients with anterior skull base defects.

Target AudienceOtolaryngologists, Head and Neck Surgeons, Allergists,Rhinologists, Residents in Training and interested Allied Healthprofessionals. The American Rhinologic Society is dedicated toproviding communication and fellowship to the members of theRhinologic community through on-going medical education,patient advocacy, and social programs.

PurposeThe American Rhinologic Society's mission is to serve,represent and advance the science and ethical practice ofrhinology leading to the improvement in professionalcompetence, performance and ultimately patient outcomes.

18

AccreditationPhysiciansThe American Rhinologic Society (ARS) is accredited by theAccreditation Council for Continuing Medical Education toprovide continuing medical education for physicians.

AMA PRA StatementARS designates this educational activity for a maximum of 8AMA PRA Category 1 Credit(s)™. Physicians should onlyclaim credit commensurate with the extent of their participationin the activity.

Conflict of Interest PolicyThe “Conflict of Interest Disclosure Policy” of the AmericanRhinologic Society requires that faculty participating in anyCME activity disclose to the audience any relationship(s) witha pharmaceutical or equipment company. Any presenterwhose disclosed relationship prove to create a conflict withregard to their contribution to the activity, or who refuses toprovide all their conflict of interest information will not bepermitted to present.The American Rhinologic Society also requires that facultyparticipating in any CME activity disclose to the audiencewhen discussing any unlabeled or investigational use of anycommercial product, or device, not yet approved for use in theUnited States.All faculty participating in a CME activity and/or any person ina position to control the content of a CME activity mustcomplete a conflict of interest (COI) form in its entirety.These will be reviewed by the CME Committee Chair and thecommittee members.If there is a question about the potential for a real conflict ofinterest, then the ARS Conflict of Interest Committee willcontact the faculty and either satisfactorily resolve thepotential conflict of interest, so as to allow the faculty to makea presentation by either clarification of the potential COI, ormodification of the COI, or not permit the faculty to present atthe CME activity, should the COI be real and irresolvable.

Oral Presentations

22

7:00 AMBreakfast SymposiumPoint of Service in RhinologyModerator - Brent Senior, M.D.

8:00 AMWelcome & Opening RemarksJames Stankiewicz, M.D.

8:07 AMTNF-alpha Inhibits Olfactory Regeneration in a TransgenicModel of Chronic Rhinosinusitis-Asssociated OlfactoryLossJustin Turner, M.D., Kai-Li Liang, M.D., Lindsey May, BS,Andrew Lane, M.D.Baltimore, MD

Introduction:Olfactory loss is debilitating symptom of chronic rhinosinusitis(CRS). While olfactory sensory neurons (OSNs) are normallyregenerated constantly in the olfactory epithelium (OE), atransgenic model of CRS-associated olfactory loss (IOImouse) demonstrates that inflammation causes widespreadOSN loss without progenitor cells proliferation. In this study,we further examine whether the inflammatory cytokine tumornecrosis factor-alpha (TNF-a) inhibits olfactory regeneration.

Methods:40 IOI mice underwent either unilateral bulbectomy or shamsurgery and then were induced to express TNF-a in the OEfor 1 week. After sacrifice, the mice were assessed histologi-cally and with BrdU staining to determine the effect of TNF-aon olfactory regeneration.

Results:In the absence of TNF-a, bulbectomy was associated withdeath of OSNs, followed by robust proliferation of neural pro-genitors and regrowth of the OE. At 12 days post-bulbectomy,OE thickness on the operated side had recovered to approxi-mately 80% of the unoperated side. In mice in which TNF-aexpression was induced, significantly reduced proliferationwas observed, associated with failure of normal reconstitutionof OE thickness.

23

Conclusion: The mechanism of olfactory dysfunction in CRS remainsincompletely understood. Previous studies with a transgenicmouse model suggested that inflammation inhibits progenitorcell proliferation and olfactory regeneration. Here, the role ofthe CRS-associated cytokine, TNF-a, was investigated usingsurgical ablation of the olfactory bulb to stimulate synchronousOSN turnover. We find that TNF-a expression prevents normalOE recovery, supporting the role of suppressed olfactoryregeneration in the pathophysiology of CRS-associated olfac-tory loss.

__________________________________________________

__________________________________________________

8:13 AMThe Efficacy of a Novel Chitosan Gel on Hemostasis andWound Healing Following Endoscopic Sinus SurgeryRowan Valentine, M.D., Theo Athanasiadis, M.D., SimonRobinson, M.D., Peter-John Wormald, M.D.Adelaide, SA

Introduction:Postoperative bleeding and adhesion formation are the 2 mostcommon complications following endoscopic sinus surgery(ESS). Continued bleeding risks airway compromise from theinhalation of blood clots and from the aspiration of bloodstained vomitus. Additionally adhesion formation is the mostcommon reason for patients requiring revision surgery. Thisstudy aims to determine the efficacy of a novel chitosan/dex-tran gel (CD gel) on hemostasis and wound healing followingESS.

Methods:A randomized controlled trial was performed involving 40patients undergoing ESS for chronic rhinosinusitis (CRS).Immediately following surgery a baseline Boezaart SurgicalField Grading Scale was taken. Computer randomisation wasperformed one side to either receive CD gel, or no treatment(control). Boezaart bleeding scores were then calculated foreach side every two minutes. Patient’s endoscopic features ofwound healing were assessed at 2, 6 and 12 weeks after sur-gery.

24

Results:CD gel achieved rapid hemostasis with the mean time tohemostasis 2 mins (95% CI 2-4mins) compared to 10 mins(95% CI 6-‡) for the control. There was significantly lessadhesions at all time points with CD gel vs control, 2 vs 18 at2 weeks (P<0.001), 3 vs 16 at 6 weeks (P<0.001) and 2 vs 12at 3 months (P<0.001). There was no significant differencebetween CD gel and control with respect to crusting, mucosaloedema, infection or granulation tissue formation.

Conclusion:CD gel is rapidly hemostatic immediately following ESS andprevents adhesion formation, addressing 2 of the most com-mon complications of sinus surgery.__________________________________________________

__________________________________________________

8:19 AMEfficacy of an Antibiotic Eluting ChitosanGlycerophosphate Implant in the Setting of AcuteBacterial Sinusitis: A Rabbit ModelBenjamin Bleier, M.D., Jennifer Kofonow, Nazish Hashmi,Noam Cohen, M.D., Ph.DPhiladelphia, PA

Introduction:Chitosan Glycerophosphate(CGP) is a mucoadhesive polymerwhich can be used as a drug eluting sinonasal implant. Thepurpose of this study is to assess the potential for CGP as anantibiotic impregnated implant in a rabbit model of acute bac-terial sinusitis.

Methods:IACUC approved study of acute bacterial sinusitis in 12 NewZealand White Rabbits using either P. aeruginosa(n=6) or S.aureus(n=6). CGP impregnated with 50mg of either gentamicinor vancomycin was bilaterally implanted in 2 rabbits in eachgroup, respectively. The sinuses were irrigated with saline for 4days and the lavage was collected for colony forming unit(CFU) determination. Within each group, the CFU log reductionin the lavage was compared that of rabbits receiving salinealone(n=2) or a daily 80mcg/mL gentamicin or vancomycin irri-gation(n=2) and analyzed using a Student's t-test.

Results:

25

Within the S. aureus group, the CFU log reduction usingCGP+Vancomycin(-2.57±0.21) was greater than Vancomycinirrigation(-1.66±0.5, p=NS), and significantly greater than salinealone(2.46±0.97; p=0.018). Within the P. aeruginosa group, theCFU log reduction using the CGP+Gentamicin(-4.62±0.74) wasgreater than Gentamicin irrigation(-4.09±0.70) and salinealone(-1.90±0.90) however the results were not significant. In allrabbits receiving the CGP+Antibiotic implant, no viable bacteriawere present in the lavage by day 4.

Conclusions: Placement of a single antibiotic impregnated CGP implant inthe setting of an acute gram positive or gram negative bacteri-al sinusitis resulted in a greater log reduction of CFU thandaily antibiotic irrigation and lead to complete sterilization ofthe lavage within 4 days.

__________________________________________________

__________________________________________________

8:25 AMDiscussion & Audience Response Questions

8:35AMCharacterisation of Bacterial and Fungal Biofilms inChronic RhinosinusitisAndrew Foreman, M.D., Alkis Psaltis, M.D., Lorwai Tan, M.D.,Peter-John Wormald, M.D.Woodville, SA

Background:Conclusive evidence now exists that biofilms are present onthe mucosa of Chronic Rhinosinusitis (CRS) patients and it ispostulated that they may play a role in the aetiopathogenesisof this chronic inflammatory disorder. Less is known about thespecies constituting these biofilms.

Objective:The aim of this study was to develop a Fluorescence in situHybridisation (FISH) protocol for the determination and char-acterisation of bacterial and fungal biofilms in CRS.

26

Method:50 CRS patients and 10 controls were recruited for the study.Bacterial FISH probes for S. aureus, H. influenza and P.aeruginosa and a universal fungal probe were applied to sinusmucosal specimens, undergoing a standard hybridisation pro-tocol. The slides were then analysed for biofilm presenceusing Confocal Scanning Laser Microscopy (CSLM).

Results:36/50 (72%) of CRS patients had biofilms present in contrastto 0/10 Controls. S. aureus was the most common biofilm-forming organism identified in our population, present in 25/50(50%) of the CRS patients. 11/50 (22%) of CRS patients hadcharacteristic fungal biofilms present on their sinus mucosa. Conclusion: This is the largest study investigating biofilms inCRS patients and provides further evidence for a role forbiofilms in CRS. It has validated mucosal tissue cryopreserva-tion for delayed biofilm analysis. The importance of S. aureusbiofilms has been highlighted, with this species being the mostcommon biofilm-forming organism in our CRS patients.Furthermore, using a strict definition, fungal biofilms wereidentified for the first time in CRS patients.

__________________________________________________

__________________________________________________

8:41 AMActivation of Ciliary Beat Frequency in Primary Murine NasalEpithelial Cultures by the CFTR Potentiator, QuercetinBradford Woodworth, M.D., Shaoyan Zhang, Ph.D., EricSorscher, M.D., Steven RoweBirmingham, AL

Introduction: Quercetin is recognized as a potent activator of CFTR.Although the mechanism of action is incompletely understood,our prior studies indicate that quercetin works in a fashionindependent of cAMP signaling. The present study investi-gates whether quercetin is an activator of stimulated ciliarybeat frequency (CBF), an additional component of themucociliary apparatus relevant to sinonasal physiology.

27

Methods:Well-characterized primary murine nasal septal epithelial(MNSE) cultures were utilized in the current study. TransgenicCFTR-/CFTR- (knockout) MNSE cultures were also investigat-ed to rule out a CFTR dependent mechanism. Select cellswere incubated with myristoylated PKI (14-22) amide, a spe-cific protein kinase A inhibitor, to evaluate for a cAMP-depend-ent mechanism. CBF was analyzed with high speed digitalimaging and the Sisson Ammons Video Analysis system fol-lowing apical exposure and compared to controls.

Results: CBF (expressed as fold-change over baseline) was signifi-cantly increased when quercetin was applied to the apical sur-face [1.65+/-0.13 vs. 1.23+/-0.05 (control), p=0.014). CFTRknockout cultures exposed to quercitin developed an increasein CBF (1.69+/-0.08) similar to wild type indicating a CFTRindependent mechanism. PKI (14-22) amide resulted in mini-mal suppression of quercitin-stimulated CBF (1.50+/-0.05;p=0.35).

Conclusion:Quercetin works as an activator of stimulated CBF independ-ent of CFTR airway surface liquid modulation and the cAMP-dependent signaling pathway. The MNSE culture model pro-vides a means by which the mechanisms underlying quercetincan be better understood in the future, including analysis ofCFTR biochemistry, single channel gating, and cell signalingpathways following administration of the compound or relatedpotentiators.

__________________________________________________

__________________________________________________

28

8:47 AMThe Role of Hepatocyte Growth Factor/C-met in ChronicRhinosinusitis With PolypsMurugappan Ramanathan, M.D., Douglas Reh, M.D., YadongWang, BS, Andrew Lane, M.D.Baltimore, MD

Background:Hepatocyte growth factor (HGF) is a growth factor thought toattenuate Th2-driven eosinophilic airway inflammatoryresponses. Increased expression of HGF and its receptor c-Met in nasal polyps suggests a role in disease pathogenesis.The effect of HGF on human sinonasal epithelial cell (SNEC)responses to Th2 inflammatory cytokines in chronic rhinosi-nusitis with polyps (CRSwNP) has not been explored. Methods: SNECs isolated from patients with and withoutCRSwNP were grown in cell culture at the air-liquid interface.The Th2 cytokine IL-13 was applied for 24 hours in the pres-ence or absence of HGF. Eotaxin-3 and c-Met expression wasassessed using real-time PCR, immunohistochemistry, andflow cytometry.

Results:SNECs obtained from both CRSwNP and control subjectsdemonstrated markedly increased expression of eotaxin-3after exposure to IL-13. HGF significantly blocked IL-13-induced expression of eotaxin-3 in control SNECs, but not inSNECs derived from CRSwNP subjects. Despite the lack ofresponsiveness to HGF, CRSwNP SNECs displayedincreased c-Met mRNA levels after IL-13 exposure, as com-pared to controls.

Conclusion:SNECs are active participants in sinonasal mucosal immunity,expressing inflammatory mediators in response to potentialpathogens and endogenous cytokines. While Th2 cytokinescan elicit expression of pro-eosinophilic mediators by SNECs,HGF appears to have a down-regulating effect on thisresponse. In patients with CRSwNP, SNECs are resistant tothis attenuation, demonstrating continued IL-13-induced eotax-in-3 expression despite HGF treatment. Abnormalities in theregulation of epithelial cell responses to endogenouscytokines and growth factors may contribute to the persistenteosinophilic inflammatory state in CRSwNP.

29

__________________________________________________

__________________________________________________


9:03 AMPresidential AddressJames Stankiewicz, M.D.

9:10 AMDecreased Regulatory T-cells in Sinonasal Mucosa andCirculating Blood in Patients with Chronic Rhinosinusitiswith Nasal PolyposisAmanda Munoz, M.D., Peter Hwang, M.D., Do-Yeon Cho,M.D., Kari Nadeau, M.D., Ph.DStanford, CA

Introduction:Regulatory T-cells (Treg) downregulate immune responses bysecreting inhibitory cytokines. A deficiency of Treg has beenassociated with allergic asthma, but the role of Treg in chronicrhinosinusitis (CRS) and chronic rhinosinusitis with nasal poly-posis (CRSwNP) is not fully understood. This study character-ized hematologic and tissue prevalence of Treg in patients withCRS and CRSwNP compared to controls.

Methods: Sinus mucosa was collected from 17 patients undergoing endo-scopic sinus surgery (4 control, 7 CRS, 6 CRSwNP). Paraffinsections were immunohistochemically double-stained for CD3(T-cell surface marker) and FOXP3 (Treg transcription factor).The number of CD3+/FOXP3+ cells per high power field (hpf)were counted in two fields for each subject. Peripheral bloodmononuclear cells were analyzed by flow cytometry in 19patients (5 controls, 6 CRS, 8 CRSwNP) The percentage ofPMBC that were Treg was recorded (marked byCD4+/CD25high/CD127low). The average number ofCD3+/FOXP3+ cells/hpf and the percentage of PBMC that wereTreg were compared between the three study groups.

30

Results:Results: The mean number of CD3+/FOXP3+ Treg per hpfwas significantly lower in CRswNP as compared to CRS (20.6vs. 7.0, p<0.02). The mean percentage of PBMC that wereTreg was also significantly lower in CRSwNP as compared toboth control and CRS subjects (3.62% CRSwNP, 4.69% CRS,4.84% Control, p<0.05).

Conclusions: Reduced numbers of Treg are present in both the local tissueand circulating blood in CRSwNP. This may indicate a sys-temic derangement of the immune response and may offerpotential treatment targets in the future.__________________________________________________

__________________________________________________

9:16 AMPost Surgical Outcomes of Endoscopic Sinus Surgery,done for chronic Rhinosinusitis associated with BiofilmsDeepti Singhal, M.D., Alkis Psaltis, M.D., Andrew Foreman,M.D., Peter Wormald, M.D.South Australia

Background:While biofilms have been implicated in the pathogenesis ofCRS there is little evidence that there presence or absencehave any effect on the outcomes of Endoscopic Sinus Surgery(ESS). This study has been designed to address this question. Methods: A prospective, blinded study of 51 patients undergo-ing ESS for CRS was conducted. Preoperatively patientsassessed their symptoms on a 10 point Visual Analogue Scaleand completed Quality of life (QOL) measures (Sino-Nasal-Outcome-Test-20 & Global severity of CRS). Their sino-nasalmucosa was graded (Kennedy-Lund scale), and CT scansassessed (Lund-McKay scale). Per-operatively, swabs weretaken of all patients for evaluation of possible pus/bacteria/fun-gus. Random sino-nasal tissue samples were assessed forbiofilm presence using Confocal Scanning Laser Microscopy.At each post-operative visit, patients reassessed their sinussymptoms and completed QOL measures. Post-surgical stateof their sino-nasal mucosa was graded endoscopically.

31

Results: Bacterial biofilms were found in 36 (70%) of the 51 CRSpatients. Patients with biofilms presented with significantlyworse pre-operative radiology & nasendoscopy scores(p=0.0002 & 0.0037 respectively). After a mean follow-up peri-od of 12 months post-surgery, biofilm positive patients hadstatistically worse sinus symptoms (VAS: p=0.0486) andworse nasendoscopy scores (p=0.0279). They also requiredextra post-operative visits & multiple antibiotic treatments devi-ating from the standard post-operative care required by biofilmnegative patients.

Conclusion: This study showed that patients with biofilms showed evi-dence of more severe disease pre-operatively and persistenceof worse post-operative symptoms, ongoing mucosal inflam-mation & infections. This study thus strengthens evidencetowards the role that biofilms may play in recalcitrant CRS.

__________________________________________________

__________________________________________________

9:22 AMHoney: Histological Effect on Respiratory MucosaShaun Kilty, M.D., Dakheelallah AlMutairi, M.D., MelanieDuval, M.D., Joseph De Nanassy, M.D.Ottawa, ON CANADA

Introduction: Chronic rhinosinusitis (CRS) is an inflammatory disease inwhich bacteria are commonly implicated often in the form of abiofilm. Honey has been demonstrated invitro at our institutionto be an effective treatment against two common CRSpathogens both in the planktonic and biofilm forms. The pur-pose of this study was to determine if the application of honeyto respiratory epithelium would result in histological evidenceof epithelial injury.

Methods: Using a rabbit animal model, a nonrandomized controlled trialof four treatment regimes was performed with two rabbits ineach group. The left nasal cavity received a honey solution

32

once daily while the right nasal cavity was not treated. Groupsone to three were treated for 3, 7, and 14 consecutive daysrespectively, and euthanized the morning following the lasttreatment. Group 4 was treated for 14 consecutive days fol-lowed by a 14 day washout period and then euthanized thefollowing morning. The nasal respiratory mucosa was immedi-ately harvested after euthanisation. Respiratory mucosa wasexamined by light microscopy for histologic change of thetreated mucosa in comparison to the control side.

Results: Cilia were not measured quantitatively but were equally pres-ent on the treated and untreated mucosa. There was no histo-logic evidence of inflammation nor was there epithelial injuryor morphologic change of the epithelium.

Conclusions: The application of a honey solution to rabbit nasal respiratorymucosa over different treatment intervals did not demonstrateevidence of histological epithelial injury.

__________________________________________________

__________________________________________________

9:28 AM Discussion & Audience Response Questions

9:38 AM Masters in RhinologyHow I do It: Skull Base Tumors - Tips and TechiquesRoy Casiano, M.D.

9:53 AMDiscussion

9:59 AMBreak with Exhibitors

33

10:20 AMPerioperative Continuous Cerebrospinal Fluid PressureMonitoring in Patients with Spontaneous erebrospinalFluid Leaks: Presentation of a Novel TechniqueDouglas Reh, M.D., Gary Gallia, M.D., Ph.D, David Solomon,M.D., Ph.D, Abhay Moghekar, MBBSBaltimore, MD

Background: Studies have evaluated cerebrospinal fluid (CSF) pressureelevations as a potential etiology in patients with spontaneousCSF leaks. A few of these studies have utilized direct meas-urements of CSF pressure using either lumbar punctures orsimple pressure transducers over short time periods. Thereare multiple limitations with these techniques including posi-tional and diurnal variation, inadequate duration of measure-ment, and insufficient analysis of waveforms. We propose anovel technique for more accurate measurement of preopera-tive and postoperative CSF pressure in patients with sponta-neous CSF leaks.

Methods: Patients with CSF rhinorrhea or otorrhea had a lumbarcatheter placed for 24 hour continuous spinal fluid pressure(CSFP) recording prior to and 72 hours after their surgicalrepair. The CSFP transducer was leveled whenever patienthead elevation was adjusted. ECG, impedance plethysmogra-phy and oxygen saturation were analyzed and correlated withCSF pressure. We calculated mean CSF pressure as well asthe pulse waveform amplitude.

Results: One half of patients had significant oxygen desaturationsassociated with elevated CSFP. Pulse waveform amplitudescould average 31 mm Hg over several minutes in patients withmean CSFP under 10 mm Hg for over 20 hours of recording.

Conclusion: Perioperative CSFP monitoring provides continuous dataincluding mean and transient elevations in CSF pressure thatcan be correlated to other measurements such as oxygen sat-uration. This data may more accurately identify those CSFleak patients with elevated CSF pressure as well as correlate

34

these elevations to prognostic clinical information that mayimprove treatment and outcome after their surgical repair.

__________________________________________________

__________________________________________________

10:26 AMPost-operative Healing in Endoscopic Repair of SkullBase Defects: A Comparison of Three Graft MaterialsKara Prickett, M.D., Sarah Wise, M.D., John DelGaudio, M.D.Atlanta, GA

Introduction: Multiple techniques for endoscopic cerebrospinal fluid (CSF)leak repair have been described. As new graft materialsbecome available, it is important to evaluate their post-opera-tive healing characteristics.

Objective: To compare time to graft mucosalization, graft success, andpostoperative crusting in patients undergoing endoscopic CSFleak repair with acellular dermis, collagen matrices, andsinonasal mucosal grafts.

Methods: Retrospective review of sequential patients undergoing endo-scopic CSF leak repair in a tertiary rhinology practice. Thisstudy specifically evaluates time to graft and donor site heal-ing in the short-term postoperative period.

Results: Thirty-seven patients underwent 40 endoscopic CSF leakrepairs. Seventeen repairs were performed with sinonasalmucosal grafts, 10 with acellular dermis, and 13 with collagenmatrices. There was a significant difference in mean time tograft mucosalization across materials (p < 0.001). Acellulardermis grafts took significantly longer to mucosalize (11.7weeks) versus both collagen matrices (6.6 weeks) andmucosa (4.9 weeks). Graft crusting was more prolonged withacellular dermis (9.4 weeks) versus collagen matrices (5.1weeks), (p = 0.04). Graft crusting was not a significant factorfor sinonasal mucosal grafts. Donor site crusting in the mucos-

35

al group had a mean duration of 6.5 weeks. Overall successwas 100%. Two patients had partial graft loss; no patients hadCSF leak recurrence during follow-up.

Conclusions: Mucosal grafts, acellular dermis, and collagen matrices havesimilar success rates in endoscopic repair of CSF leak.Acellular dermis grafts have longer time to mucosalization andlonger duration of graft crusting than mucosal or collagenmatrix grafts.

__________________________________________________

__________________________________________________

10:32 AMEndoscopic Intracranial Resection: Case Series andDesign and Employment of a Perioperative ManagementProtocolEvan Ransom, M.D., John Lee, M.D., James Palmer, M.D.,Alexander Chiu, M.D.Philadelphia, PA

Introduction: Extended endonasal approaches revolutionized the treatmentof paranasal sinus and skull base neoplasms. Purely endo-scopic resections of intracranial pathology remain rare andchallenging. Addition of intracranial work significantly alters theperioperative risk profile and proactive management of compli-cations is key to proceeding safely. We present a detailedreview of purely endoscopic transanasal intracrainial resec-tions and the design and implication of a perioperative man-agement protocol with specific reference to skull base andneuroanatomy.

Methods: Retrospective review of all patients undergoing endoscopicskull base approaches for neoplasm at Penn between 2005and May, 2009. Selection of cases involving intracranial resec-tion for detailed review. Analysis of outcome and complica-tions by approach. Design and prospective employment of aperioperative management protocol.

36

Results: Fifteen patients underwent purely endoscopic intracranialresection. Thirteen tumors were malignant. Approachesincluded 12 transcribifrom, two transplanum-transtuberculum,and one transclival. Two major (CSF leak, electrolyte derange-ment) and four minor complications occurred. Mean follow-upwas 15 months, and 13/15 patients are free of disease. Onepatient died of recurrence; one patient is alive with disease.The perioperative management protocol designed from thesedata resulted in decreased use of lumbar drainage andincreased use of nasoseptal flap reconstruction. This protocolis now employed in all cases.

Conclusions: Purely endoscopic intracranial anterior skull base surgery isboth feasible and safe when a complete understanding of thedisease, surgery, and perioperative management is achieved.Indications for these procedures continue to expand. Futurework will include quality of life measures, neurocognitiveresults, and cost effectiveness analysis.

__________________________________________________

__________________________________________________


10:48 AMOrbital Involvement in Invasive Fungal Sinusitis: Reviewof Outcomes and Recommendation of a TreatmentParadigmLindsey Arviso, M.D., Sarah Wise, M.D., John DelGaudio, M.D. Atlanta, GA

Introduction: Orbital Involvement in Invasive Fungal Sinusitis: Review ofOutcomes and Recommendation of a Treatment ParadigmIntroduction Invasive fungal sinusitis (IFS) is a life threateninginfection of immunocompromised patients. Aggressive diseaseor delayed treatment may result in extrasinus extension andincreased morbidity. We review the incidence of orbital

37

involvement in IFS, treatment options for the orbit, and out-comes with respect to orbital function.

Methods: A 14-year retrospective review of IFS patients from a singleinstitution was performed (January 1995 to March 2009). Thestudy group was analyzed for orbital invasion with IFS. Datawas reviewed for orbital symptoms at presentation, proce-dures performed to address the orbit, and functional out-comes.

Results: Sixty-nine IFS patients were reviewed. 28 patients (41%) hadorbital involvement. Symptoms on presentation included visualloss, ophthalmoplegia, periorbital pain, periorbital/orbital cel-lulitis, and proptosis. Twenty-four (86%) underwent endoscop-ic sinus surgery for minimal orbital debridement of grosslyinvolved tissue, 8 (28%) had intraorbital antifungal irrigationcatheters placed, and 11 (39%) required orbital exenteration.Of those who retained their orbit (17), 9 (32%) survived withglobe preservation, 7 with a functional globe, and 2 retained anonfunctional globe but were spared the cosmetic defect ofexenteration. The overall mortality rate for patients with orbitalinvolvement of IFS was 39% (11 patients).

Conclusions: Orbital involvement causes significant morbidity in IFS.Conservative rather than radical debridement of periorbital tis-sue with adjunctive administration of systemic and local anti-fungals can slow disease progression to allow recovery ofimmune function and maintain a functional globe.__________________________________________________

__________________________________________________

10:54 AMIncreased Prevalence of Staphylococcus aureus inAllergic Fungal Rhinosinusitis Versus Other Subsets ofChronic Rhinosinusitis with Nasal PolypsDavid Clark, M.D., Samer Fakhri, M.D., Martin Citardi, M.D.,Ashley Wenaas, BSHouston, TX

38

Background: The pathogenesis of allergic fungal rhinosinusitis (AFRS) isthought to represent an immunological reaction to fungal anti-gens. Recent studies have implicated superantigen and non-IgE mediated mechanisms in the development of AFRS.

Objective: To assess the prevalence of Staphylococcus aureus in AFRSversus other subsets of chronic rhinosinusitis with polyps(non-AFRS). Methods Retrospective review of 41 patients withAFRS and 91 patients with chronic rhinosinusitis with nasalpolyps (CRSwNP, also termed non-AFRS). AFRS was diag-nosed based on a minimum of 4 of 5 Bent and Kuhn criteria.Bacterial cultures, fungal cultures, and total serum IgE at pres-entation were analyzed for each group.

Results: Staphylococcus aureus was significantly more prevalent in theAFRS group compared with the non-AFRS group (46% versus17%, p = 0.006). There was a higher association between fun-gus and S. aureus presence in the AFRS versus the non-AFRS group (25% vs. 2%, p = 0.001). Patients with positivecultures for S. aureus had a higher (but not statistically signifi-cant) serum IgE level compared to patients with negative cul-tures (1089 versus 579, p = 0.14).

Conclusion: Staphylococcus aureus was more prevalent in patients withAFRS versus patients with other subsets of CRSwNP. In addi-tion, the simultaneous presence of both S. aureus and funguswere found to be more prevalent in the AFRS group. Theseresults support a potential role for S. aureus in the pathogene-sis of AFRS.

__________________________________________________

__________________________________________________

39

11:00 AMUpdate to Severity Classification for Chronic RhinosinusitisTroy Woodard, M.D., Jason Champagne, M.D., StilianosKountakis, M.D.Augusta, GA

Introduction: A chronic rhinosinusitis (CRS) severity classification systemhas been previously proposed by correlating objective andsubjective clinical parameters with basic science parameters.The purpose of this study is to revisit the severity classificationsystem and confirm previous findings through the use of anexpanded patient cohort.

Methods: Analysis of prospectively collected data was performed inpatients undergoing endoscopic sinus surgery (ESS) for CRS.All patients completed a preoperative Sino-Nasal OutcomeTest (SNOT)-20 and underwent objective grading via theLund-Kennedy nasal endoscopy and the Lund Mackay CTscan scoring systems. Tissue eosinophilia was determined bypathologic examination.

Results: Two hundred eighty-one consecutive patients underwent ESSfor CRS between 2003-2008 and had completed medicalrecords. The presence of polyps was associated with higherSNOT-20, endoscopy scores, and CT scores. This trend wasalso seen in patients with either tissue eosinophilia >5 / highpower field (HPF) or asthma. Polyps were found in 81.4% ofpatients with tissue eosinophilia > 5/HPF and in 29.5% ofpatients with Â¡Ãœ5 eosinophils/HPF. Patients with bothpolyps and high tissue eosinophilia had more severe clinicalfindings than patients with polyps, but without tissueeosinophilia. Similarly, in patients without polyps, high tissueeosinophilia resulted in more severe disease than in theabsence of tissue eosinophilia.

Conclusion: We confirm the previously proposed hierarchical severity clas-sification system for CRS: Eosinophilic chronic hyperplasticrhinosinusitis: polyps with tissue eosinophilia, Non-eosinophilicchronic hyperplastic rhinosinusitis: polyps without tissue

40

eosinophilia, Eosinophilic chronic rhinosinusitis: tissueeosinophilia without polyps , Non-eosinophilic chronic rhinosi-nusitis: no polyps and no tissue eosinophilia.

__________________________________________________

__________________________________________________


11:16 AMManaging Refractory Sinusitis Surgical and MedicalConsiderations - PanelModerator: Joseph Jacobs, MDPanelists: Michael Chandler, MD (New York, NY), Martin Desrosiers, M.D., FRCSC (Montreal, Quebec, Canada)Jan Gosepath, M.D. (Germany), Amber Luong, M.D. (Houston, TX)

12:00 PMBusiness Meeting Award PresentationBreak with Exhibitors

1:00 PMPresence of Dendritic Cells Expressing Pro-Th2Costimulatory Molecules is Increased in Patients WithAllergic Fungal Sinusitis and Chronic RhinosinusitisWithout Nasal PolypsBrendan O'Connell, Jennifer Mulligan, Ph.D, Carl Atkinson,Ph.D, Rodney Schlosser, M.D.Charleston, SC

Introduction: Patients with allergic fungal sinusitis (AFS) display a Th2immune response in the sinus mucosa, though the mecha-nism by which this occurs remains unclear. Dendritic cells(DC) are antigen presenting cells that regulate both innate andadaptive immunity. Previous studies by our lab identifiedincreased numbers of DC in the mucosa of patients with AFS

41

compared to normal controls. In the current study, the pres-ence of mature DC capable of stimulating Th2 immuneresponses in the sinus mucosa was examined.

Methods: Sinonasal and inferior turbinate specimens were collectedfrom patients with AFS (n=7), chronic rhinosinusitis withoutnasal polyps (CRSsNP) (n=3) and nondiseased patientsundergoing cerebrospinal fluid leak repair or pituitary tumorresection (n=8). Tissue samples were stained immunohisto-chemically for the costimulatory molecules, CD80 (B7.1) andCD86 (B7.2), known stimulators of Th2 immune responsesexpressed by mature DC.

Results: Analysis of sinus tissue samples from patients with AFSdemonstrated increased numbers of cells staining positive forCD80 and CD86 compared to normal controls. Patients withCRSsNP also demonstrated increased numbers of matureDC, but where less than AFS. In all groups, mature DC werelocalized primarily in the subepithelial stroma. Turbinate speci-mens revealed low levels of CD80 and CD86 staining thatwere similar among all groups.

Conclusions: Patients with AFS and to a lesser extent CRSsNP, displayedincreased presence of mature DC capable of stimulating Th2immune responses. DC may play a role in the modulation ofelevated Th2 immune responses observed in patients withAFS.

__________________________________________________

__________________________________________________

42

1:06 PMTargeting TGF-beta 1 Receptors Modulates AdherentJunctions in Chronic Rhinosinusitis (CRS)Ramin Naim, M.D., Katharine Elliott, M.D., Jan Gosepath,M.D., Karl Hormann, M.D.Wiesbaden

Introduction: Various Factors Such as Atopy, Microbial Agents, FungalInfection, and Anatomic Variants are assumed to be involvedin the formation of the polypoid chronic rhinosinusitis (pCRS).A further contributing factor, in the formation of pCRS, is beta-catenin. However, the extent of the hyperproliferation of thenasal mucosa is likely linked to the induction of TGF-beta1.This study examines the interaction of these cytokines in theformation of pCRS with a view to devising a possible thera-peutical strategy.

Method: Cultured pCRS specimens from eosinophilic and non-eosinophilic pCRS were incubated with TGF-beta1 antisense,and levels of beta-catenin were determined after 48 hoursusing ELISA, Western blot, and immunohistochemistry.Normal mucosa of the inferior nasal turbinate served as con-trol.

Results: A strong decrease of beta-catenin was observed in botheosinophilic and non-eosinophilic pCRS specimens. Theresults were not dependant on the eosinophilic infiltration;however, length of the incubation and TGF-beta1 oligonu-cleotides influenced the outcome.

Conclusion: TGF-beta1 appears to play a pivotal role in eosinophilic andnon-eosinophilic pCRS. The decrease of TGF-beta1 also influ-enced levels of beta-catenin. This observation suggests thatestablishing a clinical therapeutical strategy should primaryaim at TGF-beta1.

__________________________________________________

__________________________________________________

43

1:12 PMEffect of Dilute Baby Shampoo on Nasal MucociliaryClearance in Healthy SubjectsSeth Isaacs, M.D. , Martin Citardi, M.D., Amber Luong, M.D.,Chad Whited, M.D., Samer Fakhri, M.D.Houston, TX

Introduction. Biofilm formation has been implicated as an etiologic factor inthe development of chronic rhinosinusitis (CRS). Nasal irriga-tion with dilute baby shampoo has been proposed as an anti-biofilm treatment for CRS patients. The effect of dilute babyshampoo on normal sinonasal mucosal function is unknown. Methods. Mucociliary clearance time (MCT), as measured by the time inminutes for a subject to detect a sweet taste after the applica-tion of a saccharin granules at the anterior part of the inferiorturbinate, was performed before and after nasal irrigation with50 cc of 1% baby shampoo (Johnson & Johnson, NewBrunswick, NJ) in 27 patients.

Results: Mean MCTs before and after irrigation were 12.09 (+/- 4.83)and 15.45 (+/- 7.71) minutes, respectively. The mean differ-ence, 3.37 minutes, was statistically significant (p=0.031). Pre-and post MCTs for each subject were not correlated (r=0.324;p=0.100).

Conclusion: Nasal irrigations with dilute baby shampoo increase MCT inhealthy subjects. The impact of such interventions in CRSpatients warrants further investigation.

__________________________________________________

__________________________________________________

1:18 PMDiscussion & Audience Response Questions

44

1:28 PMEndonasal Laser Tissue Welding: First Human ExperienceBenjamin Bleier, M.D., Alexander Chiu, M.D., Noam Cohen,M.D., Ph.D., James Palmer, M.D,Philadelphia, PA

Introduction:Laser Tissue Welding (LTW) is a method of creating an instantsutureless wound closure using a chromophore doped biologicsolder. The purpose of this study was to assess the technicalfeasibility and outcomes and of endoscopic LTW in humansinonasal mucosa.

Methods: Prospective, IRB approved study of 10 patients undergoingendoscopic LTW using an albumin and hyaluronic acid basedsolder for repair of mucosal injuries. Data was collected onpatient demographics, total lasing time, and volume of solderused. Wounds were prospectively followed by endoscopicexam and scored on a 0-2 scale by three blinded observers(BSB, JNP, AGC) for inflammation, thermal injury, and edema. Results were compared to control wounds using a StudentÂ'st-test.

Results: 10 patients (7 male, 3 female; average age 50, range 33-71)underwent endoscopic LTW. Total lasing time was 11±11minrequiring 0.96±0.83mL of solder per patient. Patients were fol-lowed for an average of 72 days (range 12-138) and no com-plications were noted. Solder persisted for up to 26 days andthere was no significant difference between the lased andcontrol wounds with regards to inflammation(0.87±0.72 vs.1.31±0.87), thermal injury(0.06±0.25 vs. 0.12±0.34), or edemascores(1.13±0.81 vs. 1.44±0.73).

Conclusions: Endoscopic Laser Tissue Welding is a technically feasible andrapid method of wound closure in sinonasal mucosa whichdoes not result in any significant thermal or inflammatorysequelae.

__________________________________________________

__________________________________________________

45

1:34 PMFracture of Bony Lamellae Within the Frontal RecessFollowing Balloon Catheter DilatationAyesha Khalid, M.D., Timothy Smith, M.D., Jess Mace, MPh,Nathan Sautter, M.D.Portland, OR

Background: The precise manner in which balloon catheter dilatation (BCD)alters the dimensions of the frontal recess is not well charac-terized. The purpose of this investigation was to determinewhether BCD within the frontal recess is associated withreproducible patterns of fracture in bony lamellae, to charac-terize changes between pre- and post-intervention measure-ments of the frontal recess, and to compare the degree ofchange seen with endoscopic Draf I dissection.

Methods: Eight cadaver heads underwent pre- and post-interventionendoscopic visualization and computed tomography (CT) ofthe frontal recess. Frontal recesses were assigned for eitherBCD or Draf I dissection. CT scans were evaluated by tworeviewers (principal investigator and neuroradiologist).

Results: Inter-rater reliability was strong for all measures(r>0.779,p<0.001). The sagittal and coronal dimensions of thefrontal recess increased significantly following BCD and Draf Idissection (p<0.028). Significantly less change was noted inaverage coronal dimensions of the frontal recess followingBCD compared to Draf I dissection (0.9±0.5 mm versus2.6±0.6 mm; p<0.018). Mean change in the sagittal dimen-sion was significantly less following BCD compared to Draf Idissection (1.0±0.8 mm versus 4.0±1.2 mm, p<0.018). Theanterior face of the ethmoid bulla was the most frequentlyfractured lamella following BCD (56%).

Conclusion: The sagittal and coronal dimensions of the frontal recessincreased significantly following BCD and Draf I dissection. Asignificantly greater change in dimensions of the frontal recessis observed following Draf I dissection compared to BCD. Noorbital or skull base injury was noted with either technique.

46

__________________________________________________

__________________________________________________

1:40 PMCharacterizing Methicillin-Resistant Staphylococcusaureus Infections in a Tertiary Rhinology PracticeVictoria Epstein, M.D., Barbara Przybyszewski, BS, AnneHutchinson, BA, Donald Lanza, M.D.St. Petersburg, FL.

Introduction: Methicillin-Resistant Staphylococcus aureus (MRSA) is anincreasing source of morbidity and patient concern. The aimsof this study are to determine the prevalence of MRSA inparanasal sinus cultures from a tertiary outpatient rhinologypractice, to characterize its clinical behavior as "invasive" or"non-invasive", and to report antibiotic susceptibility patterns.

Methods: Patients with sinus cultures obtained in 2007 were retrospec-tively identified and their medical records evaluated. Antibioticsusceptibility profiles of MRSA were determined and com-pared to a standardized community health system (CHS)antibiogram for the year 2006. Chi square statistical analysiswas performed.

Results: 307 patients had endoscopically directed cultures of purulentsinonasal material. 43% (47/109) of patients withStaphylococcus aureus had MRSA positive cultures, in com-parison to 64% in the CHS setting (p<0.001). The prevalenceof MRSA in the rhinologic cultured patients was 15.3%. Over90% of MRSA isolates were considered susceptible to clar-ithromycin, erythromycin, linezolid, tetracycline or trimetho-prim/sulfamethoxazole. Treatment of symptomatic MRSApatients was based on antibiotic susceptibility obtained fromendoscopically directed cultures. None of the rhinologicpatients with MRSA positive cultures exhibited clinically “inva-sive” infection.

47

Conclusions: In the outpatient rhinologic setting, Staphylococcus aureuswas less likely to be MRSA when compared toStaphylococcus aureus in CHS cultures. Sinus MRSA is typi-cally sensitive to several oral agents and it is not typicallyassociated with invasive characteristics in relatively immuno-competent hosts. Further work is needed to differentiate vari-ants of MRSA and their behavior in sinus related disease.

__________________________________________________

__________________________________________________


1:56 PMPost Sinus Surgery Nasal Irrigation: What are the RealRisks of Contamination?John Lee, M.D., Jayakar Nayak, M.D., Laurel Doghramji, RN,Alexander Chiu, M.D.Philadelphia, PA

Background: Saline nasal irrigation has become one of the most effectiveand important aspects of post-operative care following endo-scopic sinus surgery. Our institution has previously demon-strated that irrigation bottles have a risk of bacterial contami-nation during this post-operative period. However, the clinicalsignificance of this contamination including the risks to theactual irrigation fluid has yet to be determined.

Objective: To identify the risks of contamination of both the nasal irriga-tion bottle and fluid following endoscopic sinus surgery.

Methods: This was a prospective study of consecutive patients undergo-ing endoscopic sinus surgery for chronic sinusitis. All patientswere given nasal irrigation bottles with detailed cleaninginstructions pre-operatively. Nasal irrigation bottles were col-lected and cultured at 1 and 2 weeks post-operatively. During

48

the same visit, 5ml of sterile normal saline was mixed into theirrigation bottle and then cultured separately. All patientsreceived a two week course of antibiotics as part of our regularpost-operative regimen. Pre- and post-operative SNOT-22scores were collected during the patient visits.

Results: A total of 20 patients agreed to participate in the study. At 1week post-operatively, 50% of the bottles had positive cultureswith 40% of the irrigation samples testing positive for bacteria.At two weeks, the contamination in the irrigation bottle and fluiddecreased to 26.7% and 20% respectively. The most commonbacteria cultured was pseudomonas aeruginosa . Across allpatients, there was a statistically significant improvement in thepre-operative SNOT-22 score at 1 and 2 weeks post-operative-ly. However, contamination of the irrigation bottle or fluid did notadversely affect SNOT-22 outcomes.

Conclusion: Despite detailed cleaning instructions, there is a relatively highrisk of bacterial contamination in nasal irrigation bottles andfluid following endoscopic sinus surgery. Although these risksdid not translate into worse SNOT-22 scores, these results mayprovide corroborative support for the routine administration ofpost-operative antibiotics to prevent early re-infection.

__________________________________________________

__________________________________________________

2:02 PMEndoscopic Sinus Surgery in the Adult Cystic FibrosisPatient: Effect on Lung Function, Intravenous AntibioticUse, and HospitalizationOswaldo Henriquez, M.D., Sarah Wise, M.D., John Delgaudio, M.D., Arlene Stecenko, M.D.Atlanta, GA

Background: Studies of endoscopic sinus surgery (ESS) in pediatric cysticfibrosis (CF) have not demonstrated significant improvement inlung function postoperatively. Adult CF patients have not beenexamined for ESS effect on pulmonary health.

49

Objectives: To ascertain ESS impact in adult CF through objective param-eters of: pulmonary function tests (PFTs), intravenous (IV)antibiotic therapy and inpatient hospital days.

Methods: Retrospective review of adult CF patients (> 18 year old)undergoing ESS from 2006-2009 in a tertiary care hospital.Twelve-month preoperative and 12 month postoperative PFTs,IV antibiotic courses, total days of IV antibiotics, and inpatienthospital days were assessed.

Results: Twenty-two adult CF patients underwent ESS; 15 patients hadadequate data for evaluation. No significant difference wasfound between mean preopertive and postoperative FEV1(76.1 vs. 76.0) or FVC (61.2 vs. 59.9), or between best preop-ertive and postoperative FEV1 (67.4 vs. 67.1) or FVC (84.2vs. 83.0), (paired samples t-test, p > 0.05). Number of IVantibiotic couses and total number of IV antibiotic days did notdiffer between the preoperative and postoperative periods(Wilcoxon signed rank test, p > 0.05). However, number ofinpatient hospital days was signifcantly lower in the 1-yearpostoperative period (36.7) versus the 1-year preopertive peri-od (59.1), (Wilcoxon signed rank test, Z = -2.20, p = 0.028).

Conclusion: This preliminary study of ESS in adult CF patients indicatessignificant reduction in inpatient hospital days in the postoper-ative period. However, there is no evidence that ESS inprovedlung function or the need for IV antibiotics.__________________________________________________

__________________________________________________

50

2:08 PMSafety, Feasibility, and Tolerability of In-Office BalloonSinus DilationFord Albritton, IV, M.D., Michael Sillers, M.D., Roy Casiano,M.D., Jacob Johnson, M.D.Dallas, TX

Introduction: Balloon Sinus Dilation (BSD) tools are increasingly used inEndoscopic Sinus Surgery (ESS). Because BSD tools causeless tissue trauma, bleeding, and patient discomfort, incorpo-rating their use in the office setting would be attractive in thisera of cost containment. We look at patient safety, tolerability,and technical feasibility of ESS with BSD in the office setting.

Study Design:IRB approved, prospective, multicenter (10) trial.

Methods: 27 patients requiring ESS for standard indications wereoffered option of treatment in an office setting under localanesthesia. BSD tools were used in all cases. Ability toaccess and dilate the sinus, adverse events, procedure tolera-bility and pain levels were assessed. Patients were followed at1, 4, and 24 weeks (endoscopic exam and sinus symptominventories), with CT at 24 weeks.

Results: Revision and primary cases were evenly represented.Procedure was aborted in 1 patient due to intolerance, and in3 patients due to inability to access. On a pain scale of 0(none) to 5 (intense), 69.2% rated pain as 0, 1, or 2; 3.8%rated pain at 5. SNOT-20 and RSDI measures showed statisti-cally significant (p<0.0001) improvement at follow-up. CTLund- MacKay scoring improved -2.93 at 24 weeks (p=0.001).At follow-up, 89% (24/27) indicated they would have the pro-cedure again, 3 were “not sure”.

Conclusion: Performance of ESS with BSD in the office is feasible, well tol-erated, and safe. In an era of healthcare cost containment, in-office ESS with BSD offers a safe and reliable option.

__________________________________________________

__________________________________________________

51


2:24 PM5th Annual David W. Kennedy LectureshipThe Frontal SinusPeter John Wormald, M.D.

2:50 PMBreak with Exhibitors

3:10 PMNicotine Induces Resistance to Chemotherapy inNasophayngeal CancersTianjie Shen, M.D., Wei Le, M.D., Peter Hwang, M.D., DayaUpadhyay, M.D.Stanford, CA

Introduction: Epidemiologic and clinical data implicate that continued smok-ing causes progression of cancer growth and resistance totherapy in patients with cancer. The carcinogens possess abil-ity to block apoptosis, an important mechanism in the develop-ment of tumors and resistance to chemotherapy. We previous-ly demonstrated that nicotine enhance growth and proliferationin lung cancer. However, the effects nicotine, a tobacco car-cinogen that inhibits apoptosis in nasopharyngeal cancer(NPC) has not been studied before. In this study, we sought todetermine the effects of nicotine on chemotherapy-inducedapoptosis in human nasopharyngeal carcinoma.

Method: Primary human nasopharyngeal carcinoma cells were grownper protocol, treated with combination chemotherapy, and theapoptosis was assessed by TUNEL and DNA Fragmentationassays. The regulation of Mitogen Activated Protein Kinase(MAPK) and Akt signal transduction pathway was examinedby using Western blott, RTqPCR, RCR array and immunofluo-rescent staining assays.

Results: Combination chemotherapy with cisplatin (35ÂƒÃ•M) plusetoposide (20ÂƒÃ•M) caused significantly increase in NPCapoptosis as compare to single agent alone, while, nicotine, in

52

part, inhibited chemotherapy-induced apoptosis in NPC.Further, nicotine induced activation of Akt and MAPK path-ways, while, inhibition of MAPK using U0126 and Akt by phos-phatidylinositol 3-kinase inhibitor, LY294002, in part, blockedthe antiapoptotic effects of nicotine against cisplatin andetoposide-induced apoptosis in NPC.

Conclusion: Nicotine inhibits chemotherapy-induced apoptosis in nasopha-ryngeal carcinoma via the Akt and MAPK mediated signalingpathways. We speculate that nicotine may play a role in onco-genesis and resistance to cancer therapy in nasopharyngealcarcinoma.__________________________________________________

__________________________________________________

3:16 PMVideo-based Assessment of Operative Competency inEndoscopic Sinus Surgery (ESS)Kulsoom Laeeq, M.D., Dougals Reh, M.D., Andrew Lane,M.D., Nasir Bhatti, M.D.Baltimore, MD

Background: Accreditation Council for Graduate Medical Education(ACGME) requires that residency programs must have aneffective plan for assessing their residentsÂ' performance inthe six core competencies. The purpose of our study was to 1)assess feasibility and 2) construct validity of the video-basedassessment of Endoscopic Sinus Surgery skills. Study DesignA prospective observational study .

Methods Five junior residents (PGY 1-3), 6 senior residents (PGY 4, 5)and 3 attendings (Rhinology faculty) were videotaped as theyperformed ESS on cadavers in the lab. Four other facultymembers watched the recorded videotapes and rated per-formance using global and checklist assessment tools forESS. Evaluators were blinded to the identity of the performers.Rating was made feasible by allowing the raters to fast-for-ward through the tapes where appropriate. Feasibility wasmeasured by comparing the time taken to score the procedure

53

on video to that in the lab. Construct validity was calculated bycomparing the total scores and score on each item of theinstrument. For all statistical purposes p<0.05 was consideredsignificant.

Results: Our results showed construct validity with experts performingbetter than the senior residents and senior residents perform-ing better than junior residents. The time taken to evaluate thesurgeon on video was less than that in the laboratory.

Conclusion: The use of videotapes combined with the objective assess-ment tool is a feasible and valid method for assessment oftechnical skills. It has implications for programs since it willincrease the faculty buy-in and reduce the potential bias.

__________________________________________________

__________________________________________________

3:22 PMSafety and Effectiveness of Balloon Catheter Sinus OstiaDilation in the Pediatric Population: a multicenter 52 weekanalysisHassan Ramadan, M.D., Kevin Mclaughlin, M.D., GaryJosephson, M.D., Frank Rimell, M.D.Morgantown, VA

Objectives: Balloon catheter dilation of obstructed sinuses for chronic rhi-nosinusitis (CRS) has been found to be successful in adults.The safety and feasibility of balloon catheter dilation in chil-dren has been recently established. The purpose of this studywas to further study the safety and effectiveness of this tech-nology in CRS in children.

Methods: A prospective, multi-center, non-randomized evaluation wasconducted in pediatric patients diagnosed with CRS. Thirty-two patients aged 2-11 were enrolled at 5 sites. Patients wereseen at follow-up visits at 1, 12, 24, and 52 weeks post-op.Safety was assessed by rate of adverse events. Effectivenesswas assessed through measurement of patient sinus symp-

54

toms. Parent/guardians completed the SN-5 Questionnaire forall patients.

Results: Twenty-one children completed their 52 weeks follow up. Nodevice related adverse events were reported. SN-5 scoreimproved from a mean of 4.5 at baseline to a mean of 2.4 at52 weeks (a change of -2.1). Twelve (57%) children had a sig-nificant improvement of their SN-5 (> -1.5), 6 (29%) had mod-erate improvement (>-1.0 <-1.5), 3 (14%) had mild improve-ment (>-0.5 <-1.0), and none of the children had any worsen-ing of their symptoms.

Conclusions: Balloon catheter dilation of the sinus ostia in children was safeand effective at one year follow up in this group of children.Further studies comparing balloon dilation to other modalitiesof treatment in children are needed to determine its efficacy inthe treatment of CRS in children.__________________________________________________

__________________________________________________


3:38 PMEndoscopic Coblator-Assisted Management ofEncephaloceles: A Prospective StudyNicholas Smith, M.D., Kristen Riley, M.D., Bradford Woodworth, M.D. Birmingham, AL

Introduction: Numerous studies have demonstrated the efficacy and safetyof endoscopic management of CSF rhinorrhea, encephaloce-les, and anterior skull base defects. Techniques have evolvedas new instrumentation has developed, but typically involvemeticulous bipolar cautery to decrease the potential forintracranial bleeding. The present study evaluates radiofre-quency coblation as a new tool in transnasal endoscopic man-agement of encephaloceles.

55

Methods: A prospective study involving 11 patients with 13 encephaloce-les (12 spontaneous, 1 traumatic) reduced with coblation com-pared to a cohort of 7 encephaloceles (5 spontaneous, 1 trau-matic, 1 congenital) reduced with standard bipolar cautery.Main outcome measures included duration of encephaloceleremoval and bleeding events. Bleeding encountered duringremoval was considered a minor event unless more than oneattempt at cauterization was required. Other data collectedincluded standard demographics, encephalocele size, andcomplications.

Results: Average duration of coblation-assisted encephalocele removalwas 21.5 minutes compared to 65.1 minutes with standardbipolar cautery (p=0.013). Minor bleeding was encounteredduring removal with coblation in 9 of 13 encephaloceles (21events). One episode of major bleeding occurred in the cobla-tion group when an anterior ethmoid artery was encounteredduring removal. Encephaloceles reduced with bipolar cauteryalone had minor bleeding events in 5 of 7 patients with nomajor events recorded. Encephaloceles were slightly larger inthe coblation group (20.3 mm) compared to bipolar (17.3 mm)(p=0.626).

Conclusions: Radiofrequency coblation greatly increases intraoperativespeed during encephalocele removal with similar hemostasiswhen compared to bipolar cautery alone and represents auseful instrument in the management of encephaloceles.

__________________________________________________

__________________________________________________

56

3:44 PMEndoscopic Anterior Skull Base Surgery: Intra-OperativeConsiderations of the Crista Galli and Post-OperativeOutcomesJohn Lee, M.D., Evan Ransom, John Lee, M.D., Alexander Chiu, M.D.Philadelphia, PA

Background: In the realm of endoscopic skull base surgery, obtaining ade-quate dural and intracranial access is often limited anteriorlyby the anatomical boundary of the crista galli.

Objectives: 1) To measure the anatomical dimensions of the crista galli ina consecutive series of patients undergoing purely endoscopicintracranial surgery for anterior skull base tumors. 2) To reviewour management, outcomes and complications of patientswho underwent the endoscopic transcribriform approach.

Methods: This was a retrospective chart review of consecutive patientswho underwent endoscopic transcribriform surgery forsinonasal and skull base lesions with dural involvement and/orintracranial extension. Measurements of the crista galli weremade from sagittal reconstructions of the pre-operative CTscans.

Results: A total of twelve patients were identified and treated by thesenior author at the University of Pennsylvania. 11 patients(91.7%) had malignant etiologies with only one patient havinga benign skull base tumor. Complete resection with dural mar-gins was accomplished in all patients. The average post-oper-ative ICU stay was 1.4 days while the average hospital staywas 3.8 days. There were no post-operative complications.The average crista galli dimension was 12.7mm (anterior-pos-terior) and 12.9 mm (cranial-caudal dimension). Drilling of thecrista galli to obtain adequate dural access was required in 4patients (33.3%).

Conclusion: Endoscopic transcribriform surgery can be performed with rel-atively low morbidity in the management of anterior skull base

57

tumors. Knowledge of the dimensions of the crista galli isimportant in pre-operative planning for both instrumentationand access.

__________________________________________________

__________________________________________________

3:50 PMSpontaneous CSF Leaks: Delineating Predictive Factorsfor SuccessRahul Seth, M.D., Karthik Rajasekaran, BS, Amber Luong, ,M.D., Pete Batra, M.D.Cleveland, OH

Background: Spontaneous cerebrospinal fluid (CSF) leaks represent a sig-nificant challenge due to frequent association of elevatedintracranial pressure (ICP) resulting in high risk of surgical fail-ure.

Objective:The objective of this study was to review the managementstrategy for spontaneous leaks and identify risk factors for fail-ure.

Methods: Retrospective chart review was performed from 1999 to 2009at a tertiary-care medical center.

Results: A total of 105 patients underwent CSF leak repair during thistime period; 39 patients (37.1%) were treated for spontaneousCSF leaks. Mean age was 53.2 years and 33 patients werefemale (84.6%). Average BMI was 28.5. The most commonsites were cribiform plate (51%), central sphenoid (21%), andsphenoid lateral pterygoid recess (18%). All patients under-went endoscopic repair utilizing image guidance with multi-lay-ered closure in most cases. Acetazolamide was used in 12patients, while 5 patients underwent ventriculoperitonealshunting (VP). Five patients (12.8%) developed recurrent CSFleak with mean ICP of 25 cmH2O, compared to 22.8 cmH20for those without recurrent leak. All underwent successful re-

58

repair with resolution of CSF leakage at mean follow-up of 4.5years. Pearson likelihood ratio demonstrated pseudotumorcerebri diagnosis was associated with statistical higher risk ofrecurrence, while elevated BMI approached statistical signifi-cance. Age, leak site, ICP, and presence of encephalocelewere not associated with recurrence.

Conclusion: Management of spontaneous CSF leaks requires a compre-hensive strategy after endoscopic closure. Close ICP monitor-ing, coupled with selective use of acetazolamide and VPshunting, may help decrease risk of failure.


4:06 PMRadiographic Examination of Anatomic Relationships ofthe Posterior Ethmoid ArteryOswaldo Henriquez, M.D., Jodi Zuckerman, M.D., SarahWise, M.D., Amanda Corey, M.D.Atlanta, GA

Background: Anatomic relationships of the posterior ethmoid artery (PEA)are important for surgical safety in the sinuses and orbit.Previous cadaver studies have evaluated ethmoid artery posi-tion with respect to the lacrimal crest and optic foramen.

Objectives:(1) To radiologically evaluate PEA relationship to the skullbase, sphenoid face, sphenoethmoid (Onodi )cells, and intra-orbital landmarks. (2) To determine the incidence of a middleethmoid artery (MEA) and its impact on other orbital measure-ments.

Methods: Retrospective review of 50 non-diseased thin slice axial CTscans with 3D reformations (100 sides). Measurements weretaken on a neuroradiology workstation.

Results: The PEA was within the bony skull base in 95% of sides.When located on a mesentery below the skull base, the mean

59

distance to the skull base was 4.5 mm. Sphenoethmoid cellincidence was 16%. In 100% of cases, when a sphenoeth-moid cell was present, the PEA was located within it. Meandistance from PEA to sphenoid face was 7.29 mm (SD3.18mm). Mean distance from lacrimal crest to anterior eth-moid artery (AEA) was 25.6 mm, AEA to PEA was 14.0 mm,and PEA to optic foramen was 6.79 mm. MEA was present in20% of sides. MEA presence did not significantly alter themeasurements of the lacrimal crest to AEA (25.57mm), theAEA to PEA (14.0mm), and the PEA to the optic foramen(6.79mm), (p = NS). Conclusion: This study provides impor-tant PEA anatomic measurements with respect to frequentlyencountered surrounding structures.

__________________________________________________

__________________________________________________

4:12 PMTopical Epinephrine is Safe in Endoscopic Sinus SurgeryRichard Orlandi, M.D., Smitha Warrier, M.D., Stephan Sato,RN Salt Lake City, UT

Introduction: The safety of topical epinephrine (1:1000 concentration) hasrecently been called into question. No objective data has beenpresented examining this issue.

Methods: We retrospectively reviewed all cases of endoscopic sinussurgery performed by the senior author performed betweenJuly 2000 and January 2008. Perioperative records werereviewed for use of topical 1:1000 epinephrine and for anyintraoperative or postoperative complications related to itsuse.

Results: Of 1162 total surgical procedures during this period, therewere 810 endoscopic sinus surgery cases. Of these, topical1:1000 epinephrine was used in 712 (88%). One case ofthese 712 (0.1%) developed transient intraoperative hyperten-sion immediately following inadvertent submucosal injection of

60

concentrated epinephrine. This event was due to an erro-neous switch with the 1% lidocaine/1:100,000 solution. Thiserror occurred early in our institutionÂ's experience with con-centrated topical epinephrine. Following implementation ofadditional preventative safeguards, no further errors or compli-cations have occurred.

Conclusion: Concentrated epinephrine has the potential for complicationswhen used incorrectly. Nevertheless, with appropriate safe-guards described herein, its topical use is safe for limitingbleeding during endoscopic sinus surgery.

__________________________________________________

__________________________________________________

4:18 PMThe Role of Stenotrophomonas maltophilia in RefractoryChronic RhinosinusitisDavid Grindler, Pete Batra, M.D., Geraldine Hall, Ph.D Cleveland, OH

Background: Stenotrophomonas maltophilia is a multi-drug resistant gram-negative bacillus that has been implicated in serious nosoco-mial infections. The organism has also been isolated fromsinus cultures in refractory chronic rhinosinusitis (CRS).

Objective:The objective of this study was to elucidate the implications ofS. maltophilia positive cultures in CRS.

Methods: Retrospective review was performed on 101 patients withrefractory CRS with sinus cultures positive for S. maltophiliaisolates over a 5-year period.

Results: The mean age was 56.9 years with a female:male ratio of1.1:1. Previous sinus surgery had been performed in 90.1% ofpatients. Greater than 97% of patients had prior antibioticusage. The most common symptom was discolored nasal

61

drainage (76.2%) with endoscopic evidence of pus or crustingin 83.2%. Monotherapy with trimethoprim/ sulfamethoxazole(TMX) and quinolones was utilized in 40.6% and 25.7%,respectively. This resulted in clinical improvement in 70% ofcases. Interestingly, 20.0% and 8.0% of samples exhibitedresistance to TMX and quinolones, respectively. Repeat cul-tures were performed at the follow-up visit in 69 cases.Negative cultures were associated with clinical improvement in71.4% of patients. In contrast, only 21.4% with persistent S.maltophilia positive cultures showed clinical improvement.

Conclusions: The presence of S. maltophilia isolates on culture is associat-ed with clinically relevant symptoms and endoscopic findings.Despite its multi-drug resistant nature, monotherapy with TMXand quinolones appears to be effective in clinical improve-ment. Patients with negative cultures on repeat endoscopywere more likely to obtain symptom relief than patients withongoing S. maltophilia infection.

__________________________________________________

__________________________________________________


4:34 PMMasters in RhinologyHow I Do It: Endoscopic Modified Lothrop Procedure,Tips and TechniquesPeter John Wormald, M.D.

62

#101 Characterization of Bacterial Microbiota in Post-Surgical Maxillary Sinus of Chronic Rhinosinusitis (CRS)Patients Using Molecular 16S rRNA Gene-Based AnalysesCindy Liu, M.D., Paul Keim, Ph.D, Andrew Lane, M.D.Flagstaff, AZ

Introduction: Despite the prevalence of chronic rhinosinusitis (CRS), evi-denced-based antimicrobial use in CRS remains challengingbecause the microbial communities (i.e., microbiota) of theparanasal sinus remain unknown. In this preliminary study, weapplied 16S ribosomal RNA (rRNA) gene-based pyrosequenc-ing and community ecological analysis to assess the maxillarysinus bacterial microbiota.

Methods: Lavage and swab samples were collected from post-surgicalmaxillary sinuses. All samples were collected under endoscopicguidance and underwent complete cell lysis and DNA extrac-tion. Bacterial load was quantified using broad-coverage 16Squantitative PCR, followed by PCR amplification using barcod-ed 16S fusion primers. Pyrosequencing was performed on the454® platform using the XLR Titanium chemistry.Pyrosequencing data were processed, quality-checked, andtaxonomically classified. Rarefaction, diversity, and bacterialcommunity ecological analyses were also performed. Results: Atotal of 23 unique bacterial families were detected, with a rangeof 3-11 unique bacterial families in each sample.Pseudomonaceae was the most abundant bacterial family, fol-lowed by Staphylococcaceae, Enterobacteriaceae,Corynebacteriaceae, and Streptococcaceae. A wide range inbacterial phylotype richness and diversity and in microbiotacompositions was found in the CRS sinus.

Conclusion: Here, we performed the first 16S rRNA gene-based pyrose-quencing characterization of maxillary sinus microbiota. Wefound a high level of inter-patient heterogeneity, but we alsoobserved that patients appear to fall into two groups: singledominant phylotype and multiple dominant phylotypes, with thelatter observed in nasal polyposis (NP) patients on oral steroidtherapy, as compared to non-treated NP patients.

Poster Presentations

63

#102 Complementary and Alternative Medicine for ChronicRhinosinusitis: A Review of the LiteratureRajanya Petersson, M.D., Kyle Burkhamer, David Archibald,M.D., Oren Friedman, M.D.Rochester, MN

Introduction: Chronic rhinosinusitis (CRS) affects approximately 14% of theU.S. population. Conventional treatments include nasal irriga-tions, steroid nasal sprays, systemic steroids, antibiotics, andsurgery, with limited lasting efficacy in CRS. As such, CRSpatients may turn to complementary and alternative medicine(CAM) therapies. This study aims to review the use of CAMamong CRS patients and identify potential effective CAM thera-pies for CRS.

Methods: A systematic review of the English language literature.Inclusion criteria: in vivo human studies, reviews, surveys, andcase reports/series. Exclusion criteria: animal trials and in vitrostudies.

Results: Review of survey studies show that up to 65% of patients withrhinologic complaints use CAM, which ranges from herbal ther-apy, exercise, dietary management, chiropractic care, andacupuncture. Although there are several randomized, controlledtrials (RCT) for CAM in acute rhinosinusitis, RCT data for CAMin CRS is scant. Bromelains and BNO-101 have been shown tobe promising for the treatment of CRS through RCT's. Otherstudies suggest potential therapies (e.g. homeopathic thera-pies, cod liver oil, Manuka honey) that need further evaluation.

Conclusions: Chronic rhinosinusitis is a frustrating disease process with no"cure." Although several studies show CAM use among rhinolo-gy patients, including those suffering from CRS, few RCTshave been performed with such therapies in CRS patients. Webelieve CAM deserves attention in regards to CRS, as a signifi-cant proportion of patients will turn to these therapies. With lim-ited efficacy of conventional therapies in CRS, there may be anincreasing role for CAM in this disease process.

64

#103 Computed Tomography Evaluation of Nasal ValveChanges with 2- and 3-mm Spreader GraftsDavid Archibald, M.D., Rizwan Siwani, M.D., John Pallanch,M.D., Oren Friedman, M.D.Rochester, MN

Introduction:Nasal obstruction at the level of the internal nasal valve canbe treated by a variety of surgical techniques and approaches.The use of spreader grafts has been widely debated as towhether this technique is truly capable of widening the nasalvalve and relieving nasal obstruction. The purposes of thisstudy are to show that the nasal airway truly is widened withthe insertion of spreader grafts and to compare the effectivenessof 2-mm and 3-mm wide spreader grafts in increasing nasalvalve area and volume, using computed tomography (CT).

Methods: Two sets of silastic spreader grafts, 2-mm then 3-mm wide,were inserted into 4 cadavers. Postoperative CT scans wereobtained after the placement of each spreader graft. Changesin volume and area were calculated by using packaged soft-ware.

Results: The mean increase in nasal volume and surface area in sub-jects that received 2-mm spreader grafts and then subsequent3-mm spreader grafts was .73 cm3 (sd = .53 mm3) and 13.47mm2 (sd = 11.9 mm2), respectively. A paired t-test statisticalanalysis demonstrated a significant increase in volume (p =0.006) and surface area (p = 0.015) with the 3-mm grafts.

Conclusions: The use of 3-mm wide spreader grafts increases the nasalvolume and area greater than 2-mm grafts as measured usingCT imaging, an objective test that has been used to measurethe nasal valve and airway.

#104 Controversies in Management of IntracranialAngiofibroma: A Literature Review and PersonalExperienceMoshen Naraghi, M.D., Shabnam Mortazavi, M.D., Yasir AndrabiTehran, Iran

65

Objective: Juvenile nasopharyngeal angiofibroma (JNA) is a benign butlocally invasive tumor of the nasopharynx that is found primari-ly in the teenage male. Although surgery is the mainstay oftreatment of these tumors, management of more aggressivetumors with extensive intracranial extension has been a matterof discussion. Our literature search was conducted with the keywords of angiofibroma and intra cranial extension, to gain anoverview of various options in the management of these lesionswhile we present our experience on of some extreme cases.

Methods: 151 patients were found to have angiofibroma with intracranialextension. Various approaches were employed in gainingaccess to these lesions, which included surgery, radiotherapy,chemotherapy or combination of these modalities.

Results: Surgical approach was the sole treatment modality in 85patients. Surgical excision of tumors was performed throughvarious approaches ranging from minimally invasive endoscop-ic approaches to the most radical craniotomy approaches. 46patients were managed by radiotherapy alone. 19 patientswere treated by combined surgery and radiotherapy approach.1 patient was managed by chemotherapy followed by radio-therapy

Conclusion: There is a wide spectrum of intracranial extension of angiofi-broma with different involvements and the approaches havebeen used differently by many surgeons so that it is difficult tocompare the results of surgical reports of all of different series.Because. Applying various approaches also depends on thedura involvement or perforation, cavernous sinus involvementand feeding vessels of tumor. In addition to this, recurrencerates in all cases were obviously much higher for more exten-sive stages by any approach.

#105 Ectopic Pituitary Adenoma With Apoplexy Presentingas Dlival MassPamela Mudd, M.D., Todd Kingdom, M.D., Kevin Lillehei, M.D.,Bette DeMasters, M.D.Denver, CO

66

Summary: Authors present a case report from a tertiary care facility of a78 year old male presenting with apoplexy, found to have anectopic pituitary neoplasm with necrosis and features ofapoplexy isolated to the clivus.

Objectives: 1. Learn the unique embryology of the pituitary gland to appre-ciate development of ectopic focus of disease. 2. Add ectopicpituitary adenoma to your differential when approaching skullbase tumors

Methods: The authors present a case of a 78 year old male presenting toa tertiary care center with cranial nerve VI palsy and a clivalmass. A combined otolaryngology-neurosurgical approach tothe clivus through endoscopic trans-sphenoidal approach wasperformed for resection of the mass. Immunohistochemicalstains and pathologic assessment confirm an ectopic pituitaryadenoma with apoplexy.

Results: Ectopic pituitary neoplasms have been described in the litera-ture and most commonly occur within the sphenoid sinus ornasopharynx. Few case reports have described the rare entityof ectopic pituitary within the clivus. The unique embryology ofthe pituitary is described as it relates to this rare entity. In addi-tion a review of the current literature is presented.

Conclusion: Ectopic pituitary adenoma within the clivus is a rare clinicalentity. As otolaryngology-neurosurgery combined approachesto the skull base increase, knowledge of both common andrarer pathology of the skull base must be appreciated.

#106 Endoscopic Resection of Schneiderian Papillomaswith Inferior Turbinate PreservationKimberly Rutherford, M.D., Seth Brown, M.D. Farmington, CT

Introduction: Schneiderian papillomas are histologically benign, but locallyaggressive lesions with high recurrence rates and a small riskof malignant conversion. Previous management techniques

67

involved a large en bloc surgical resection utilizing an externalapproach. This resulted in high surgical morbidity, includingatrophic rhinitis.

Objectives:The objectives of this study were to present and review theendoscopic surgical technique used to excise maxillary sinuspapillomas with preservation of the inferior turbinate, evaluatepatient characteristics that allow for successful excision, andexamine the recurrence rates.

Methods: A retrospective chart review of patients with the clinical andpathological diagnosis schneiderian papillomas of the maxillarysinus that were excised endoscopically with inferior turbinatepreservation was conducted. Patient demographics, locationand extent of the lesion, surgical techniques, and follow-up out-comes were evaluated.

Results: Four patients with inverted or oncocytic schneiderian papillo-mas of the maxillary sinus that were endoscopically excisedwere identified. The average age was 68 years old and allwere female. Extent of the lesions ranged from involvement ofonly the maxillary sinus to involvement of the maxillary andethmoid sinuses with extension to nasal cavity, nasopharynx,and skull base. All lesions were excised using an endoscopicapproach with preservation of the inferior turbinate. At a mini-mum of 1 year follow-up, all patients were free from recurrence.

Conclusions: Endoscopic resection of schneiderian papillomas of the maxil-lary sinus with inferior turbinate preservation provides a mini-mally invasive surgical technique with decreased surgical mor-bidity, including atrophic rhinitis. Initial results with respect torecurrence rates are promising.

#107 Endoscopic Sphenoid Balloon SinuplastyB. Todd Schaeffer, M.D. Lake Success, NY

This video describes and demonstrates how a non- radiationballoon sinuplasty is performed of the sphenoid sinuses. Usinga light cable as the guide through a zero degree guide

68

catheter, the light cable is visualized inside the sphenoid sinusby trans-illuminating the sphenoid sinus. This is seen endo-scopically and avoids the use of radiation guidance of a C-arm

#108 Extended Inferior Turbinate Reduction in the NarrowNoseAndrew Lerrick, M.D., Alexis Mandli, PA-C, Chicago, IL

Introduction: Hypertrophic inferior turbinates contribute to nasal obstruction.In narrow passageways the turbinates occupy a disproportion-ately greater area. In this instance additional turbinate tissuemust be removed to achieve a satisfactory airway. Anatomy:The nasal passageway directs a significant proportion ofinspired air through its lower third. The narrow nose is particu-larly vulnerable to inferior septal deflections and step-off defor-mities. The distance between the septum and the entire medi-al aspect of the inferior turbinate is measured. DiagnosticTesting: Acoustic rhinometry measures nasal airway dimen-sions by emitting wide-band signals and digitally analyzing thereflected waves, providing a topographic display of the septal-turbinate relationship. Standardized values have determinedthe narrowest septal-turbinate distance to measure 4.5mm,occurring between 1.90-2.00cm from the nostril. Narrowingcan be visualized using a 4.0mm rigid nasal endoscope. Inextreme cases, a 2.7mm scope is utilized. Rhinomanometrymeasures nasal airflow. Endoscopy, rhinometry, and rhino-manometry should be performed in the natural and decon-gested states.

Methods: Reduction can be achieved by a number of methods, includingsub-mucosal debridement and full-thickness resection. Givencomparable soft-tissue thickness, differential bone resectioneffectively compensates for pre-existing turbinate asymmetry.The septal contribution is determined by comparing the septal-turbinate distance with the total turbinate-to-turbinate distance.Septoplasty should precede turbinate resection, to allow vari-able turbinate reduction, if necessary.

Results: Quantitative measurements can be obtained intra-operativelygiven the portability of rhinometry testing equipment. Data can

69

be compared to more modest turbinate reduction commonlyperformed in patients with typical nasal anatomy. Conclusion:Narrow nasal passageways require extended inferior turbinatereduction to compensate for external anatomic limitations.Rhinometry and rhinomanometry can prepare the surgeon forthis necessity to optimize results.

#109 Gender and the Presentation of ChronicRhinosinusitisDavid Lin, Rakesh Chandra, M.D., David Conley, M.D., Robert Kern, M.D.Chicago, IL

Background: The effect of gender on severity and phenotype of chronic rhi-nosinusitis (CRS) remains an area of investigation. This issuewas studied in a sample drawn from a large university-basedpractice.

Methods: The study population included 106 CRS patients (47F, 59M)prospectively enrolled into a allergy/sinus center database.Patients were stratified by gender and phenotype: CRS withnasal polyposis (CRSwNP) or CRS without nasal polyposis(CRSsNP). Data was collected regarding Lund-Mackay score,asthma status, and sensitivity to eight classes of aeroallergens.

Results:The prevalence of CRSwNP phenotype was similar betweengenders (34-40%). CRSwNP patients had significantly greaterLund-Mackay score than those with CRSsNP (p<0.001), butno gender differences were observed. Patients with CRSwNPwere more likely to manifest asthma than those with CRSsNP,but this only reached statistical significance for males(p=0.0187). Almost 50% of patients were atopic, and this didnot differ by gender or phenotype. Among atopic patients,however, males with CRSwNP were sensitive to a greaternumber of aeroallergen classes than females (5.3 versus 2.6;p=0.04).

Conclusions:Gender did not influence the prevalence of CRSwNP pheno-type or the radiologic severity of CRS in this series. Asthmaand atopy may be more significant cofactors in males.

70

#110 Glomangioma of the Nasal SeptumDaniel Monin, M.D., Mayuri Desai, M.D., Rhoda Wynn, M.D.

Glomangiomas are benign vascular neoplasms that arise fromthe glomus body, a neurovascular structure that functions inthermal regulation. They are rare in the head and neck, withonly 13 prior cases reported involving the nasal cavity or sinus-es. We present a case of a glomangioma of the nasal septum.A 26-year-old woman with history of Neurofibromatosis Type Ipresented with a lesion on the nasal septum associated withdiscomfort, crusting, and epistaxis. Endoscopic excision of themass was performed and at 5 months follow-up there was noevidence of recurrence. The clinical presentation, immunohisto-logical features, differential diagnosis, and management of thistumor with a review of the literature are discussed. Completeexcision is curative in most cases.

#111 Inadequate health insurance cost coverage a majorfactor in discontinuation of subcutaneous immunotherapyfor Allergic RhinitisRavi Surender Vaswani, M.D., Yi-Chun Carol Liu, M.D., Leena Parikh, M.D.Columbia, OH

Background: Despite proven efficacy and safety of subcutaneousimmunotherapy, for allergic rhinitis many patients discontinueallergy injections prior to the recommended duration of 3-5years, thereby not deriving full benefit.

Objective: To examine the causes of premature discontinuation of subcu-taneous immunotherapy.

Methods: The data was collected on patients who stopped subcutaneousimmunotherapy prior to the completion of prescribed duration.The patients were contacted via phone or letter to identify thereason for stopping allergy injections.

Results: A total of 103 patients terminated subcutaneous immunothera-py prematurely. Sixty two percent were on maintenance doseand 38% were in escalation dose phase. Forty seven (45.6% )

71

were males and 56 (54.4%) were females. The reasons citedfor early drop out were: inadequate insurance coverage(39.8%), inconvenience (16.5%), concurrent health problems(9.8%), patient-perceived ineffectiveness (5.8%), change ofresidence (1.9%) and trial of alternative medicine (1%). Theremaining 25.2% did not provide any reason for withdrawingfrom receiving subcutaneous immunotherapy. Of these, only 3patients had full insurance coverage for the allergy injectionsand the rest did not.

Conclusion:Inadequate insurance reimbursement is a major contributingfactor for premature discontinuation of subcutaneousimmunotherapy in patients with allergic rhinitis. Subcutaneousimmunotherapy has been shown to be an effective treatmentof allergic rhinitis and improvement of health insurance bene-fits would allow for better utilization of this treatment option.

Poster #112 Local Nasal Immunotherapy For AllergicRhinitis: A Systematic ReviewStephen McDonald, FRCSBristol, UK

Objective: To systematically review the evidence for local nasalimmunotherapy (LNIT) compared to placebo for allergic rhini-tis, using outcome measures of symptom scores, medicationused, and adverse events.

Methods:The review was carried out according to Cochrane Reviewmethodology. Randomised controlled trials were soughtthrough a systematic search of major online databases(Medline, EMBASE, Cochrane CENTRAL, CINAHL, AMED).

Results: 12 studies were included. Of these, 8 in total contributed tometa-analysis. There was a significant reduction in symptomsfor participants taking LNIT in studies presenting ordinal data(Risk Reduction = 0.23, 95% confidence interval (CI) 0.15 to0.36; p <0.00001). In studies presenting continuous data,there was an overall trend towards reduced symptoms forLNIT (standardised mean difference (SMD) -0.42, 95%CI -1.07 to 0.24; p =0.22). For seasonal allergens, the reduction in

72

seasonal symptoms was significant (SMD -1.56, 95%CI -2.61to -0.51; p = 0.004) following LNIT. Use of medication wasreduced in those taking immunotherapy (SMD -0.61, 95%CI -1.04 to -0.18]; p = 0.006). There was a non-significantincrease in mild adverse events in the treatment group, andno serious adverse events.

Conclusions: LNIT is a safe treatment that significantly reduces symptomsand medication requirements in allergic rhinitis. Despite het-erogeneity, findings are consistent across the majority of stud-ies. Further research is needed to establish the ideal doseand treatment duration, and to compare efficacy and ease ofuse with other methods of immunotherapy application (sublin-gual and injection routes).

#113 Management of Sinusitis and Graft Preservation afterSinus Lift ProcedureAshutos Kacker, M.D., Caroline Yoon, M.D., Deya Jourdy, M.D.New York, NY

Introduction: Oral rehabilitation with the sinus lift procedure has been highlypopularized. However, the complication of sinusitis followingthis procedure and the relationship of sinus lift graft preserva-tion has not been thoroughly evaluated. The objective of thispaper is to examine sinusitis management following sinus lift-ing and to identify factors that necessitate graft removal.

Methods: Retrospective chart review. The study population consists of acase series of 9 patients referred to a single otolaryngologistwith a history of a sinus lift procedure. All patients presentedfor treatment between August 2005 to May 2009.Retrospective chart review was performed to examine demo-graphic data, history, treatment, and postoperative manage-ment.

Results: All patients were initially treated medically by their oral sur-geon without improvement. Additionally, every patientsrequired endoscopic sinus surgery with maxillary antrotomies.The sinus lift graft material was left intact in all patients excepttwo that had extrusion to the cheeks associated with facial

73

cellulitis, demanding graft removal and debridement. Mean fol-low-up was 10 months with full resolution of symptoms in theentire study group.

Conclusions: Sinusitis refractory to medical management after sinus liftingshould be evaluated by an otolaryngologist and will likely requiresurgical intervention. Graft removal is indicated when graft extru-sion or migration into the soft tissues of the face occurs.Otherwise patients who develop sinusitis following sinus lift canbe safely managed by sinus surgery with graft preservation.

#114 Massive Cerebral Infarction after Embolization forNasopharyngeal AngiofibromaMoshen Naraghi, M.D., Shabnam Mortazavi, M.D., Masoud Boroojerdi, M.D.Tehran, Iran

Introduction: Juvenile nasopharyngeal angiofibroma (JNA) is a relativelyrare, histologically benign non-encapsulated vascular tumorthat can be extended even beyond the skull base due to itsaggressive behavior. Surgical excision preceded by emboliza-tion to provide less bloody field during operation is an option insurgical resection of JNA. Embolization depends on the patient`sangiography to specify supplying arteries of the tumor. There arerare complications following the embolization, most of them arethe result of thromboembolic events. In this article we present arare and severe complication of embolization.

Case report: A 52 year-old JNA patient with history of multiple surgical exci-sions, the last procedure proceded by preoperative emboliza-tion was referred to our center with left sided blindness despitelarge residual tumor. Cranial nerves examination showed III,IV, V, VI paralysis. Based on the patient`s angiography it wasrevealed that a left middle cerebral artery infarction occurreddue to embolization.

Conclusion: Prevention of potentially hazardous complications following thepreoperative embolization needs an accurate angiography anduse of appropriate embolic agents by expert interventionalradiologist.

74

#115 Maxillary Pneumocele: A Case Presentation withProgressive SymptomsMoshen Naraghi, M.D., Yasir Andrabi, M.D., Sbabnam Mortazavi Tehran, Iran

Introduction: Maxillary pneumoceles are rare conditions characterized bypathological expansion of paranasal sinuses with thinning ofthe bony walls and displaces adjucent structures. Theselesions may remain asymptomatic over long periods and rarelypresent with classic signs. We present a very rare case ofmaxillary pneumocele presenting with a progressing cascadeof symptoms.

Method: A 10 year old boy presented with progressive left maxillary painfrom 9 months. It had a typical cascade beginning with thenumbness of the left upper lip, then anesthesia of the canineteeth with gum around it, and finally the center of pain wasdeep orbit. He also experienced two episodes of severe orbitalpain with barotrauma during descent in travels to the mountain-ous regions. The parents also had noted swelling of the leftcheek since two years ago.

Result: The patient underwent functional endoscopic sinus surgerybased on the presumed etiology of occlusion of the maxillarysinus ostium by one-way valve. There was significant improve-ment of symptoms after surgery. Conclusion: Maxillary sinus isthe least affected sinus by pneumoceles. Most pneumocelesremain asymptomatic over long periods and are not diagnoseduntil there is an external deformity or the displacement of adja-cent structures causing symptoms. Treatment is based onrelieving one-way valve mechanism as we reported in our caseof maxillary pneumocele.

#116 Modulation of Ambient Air Pollution-Induced NasalEpithelial Inflammation by Protein Kinase C- subtype inHumansDo-Yeon Cho, M.D., Wei Le, M.D., Daya Upadhyay, M.D.,Peter Hwang, M.D.Stanford, CA

75

Introduction: Air pollution particulate matter (PM) is the sum of all solid andliquid particles suspended in air, many of which are haz-ardous. An exposure to PM is known to induce inflammatoryresponses in the airways which can enhance symptomaticpresentations of acute or chronic rhinosinusitis (RS). Althoughthe etiology of RS is multi-factorial, ambient air pollution partic-ulates play a critical role in mediating airway inflammation.However, precise molecular mechanisms underlying theseeffects have not been identified. In this study, we sought todetermine whether the differential regulation of Protein KinaseC (PKC)-subtypes modulate PM-induced airway inflammation.

Methods: Primary human nasal epithelial cells were cultured as per pro-tocol and exposed to ultra-fine PM (< 2.5uM). The effect ofactivation of PKC subtypes on the release of PM-inducedinflammatory mediators was examined by using RTqPCR,PCR-array and immunofluorescent staining assays. Results: We demonstrate that PM caused activation of variouscytokines and chemokines in primary human nasal epithelium,and induced differential activation of PKC subtypes gamma,epsilon, eta and zeta. Modulations of PKCs blocked the effectsof PM on in the nasal epithelium suggesting that the differen-tial regulation of PKCs mediate PM-induced inflammation inthe nasal epithelium.

Conclusion: Air pollution may enhance sinonasal inflammation. Selectivemodulation of PKC-subtypes may be used as potential targetsfor therapeutic intervention.

#117 Olfactory Dysfunction in Allergic Fungal SinusitisCarl Philpott, M.D., Leo Lai, Gina Zheng, Amin Javer, M.D.Canada

Background: Allergic fungal sinusitis is a chronic disease which requiressustained medical therapy following endoscopic sinus surgery.However patients appear to complain of olfactory dysfunctionin spite of apparent control of their disease based on endo-scopic assessment of their sinus cavities.

76

Objective: Patients with allergic fungal sinusitis often complain of hypos-mia even when their mucosal disease in the sinus cavities iswell controlled. This study aims to correlate subjective report-ing of olfactory function with endoscopic staging and perform-ance on the Sniffin' Sticks test.

Methods: 60 patients with allergic fungal sinusitis seen in a tertiary rhi-nology clinic were recruited to undergo olfactory testing follow-ing routine endoscopic follow up.

Results: There was a significant correlation between patients' perform-ance on the Sniffin' Sticks and endoscopic staging and withtheir reported olfactory ability (p<0.001).

Conclusion: All patients with significant sinonasal inflammatory diseaseshould receive evaluation with olfactory testing and be treatedon their merit.

#118 Orbital Extension of Nasopharyngeal AngiofibromaMoshen Naraghi, M.D., Shabnam Mortazavi Tehran, Iran

Introduction: Juvenile nasopharyngeal angiofibroma (JNA) is a most com-mon benign tumor of the nasopharynx that is found primarilyin the young male. JNA has a well defined boundary, so itsextension to the orbit causes pushing of the orbital contentswithout a true infiltration. There have been different approach-es to gain access to the orbital extension of these lesions. Todate, there has been no review study to evaluate manage-ment of orbital extension of JNA. So we present a review ofliterature and our experience.

Methods: A literature search was conducted with the key words of angiofi-broma and orbital extension, in Medline to gain an overview ofvarious options in the management of these lesions.

Results: Twenty six patients were found to have angiofibroma with

77

orbital extension. All of them had various levels of ophthalmicdisturbances from proptosis to blindness other than typicalJNA symptoms such as epistaxis and nasal obstruction.Various approaches were employed in gaining access tothese lesions, which included surgery, radiotherapy,chemotherapy or combination of these modalities. Nineteenpatients were managed by surgical approach alone. Whichincluded endoscopic surgery, facial translocation, fronto-tem-poral craniotomy, orbitozaygomatic osteotomy and medialmaxillotomy. Three patients were treated by combined surgeryand radiotherapy. One patient was managed by chemotherapyfollowed by radiotherapy. Gamma knife surgery following theradical craniotomy was performed for 1 patient.

Conclusion:The principle method of management of orbital involvement ofJNA remains surgery. Selection of a surgical approach is deter-mined by surgeon factors, tumor factors and the other sites ofJNA extension accompanied with orbital involvement. Despitethe relative effectiveness of radiotherapy to treat advanced andrecurrent tumors, it is associated with side effects in youngpatients and potential effects on vision. So most authorsreserve it for far advanced cases with limitation of surgery.

#119 Positive Fungal Cultures in Allergic and Non-AllergicFungal SinusitisChristopher Melroy, M.D., Charles Ebert, Jr. M.D., Jared Intaphan, M.D., Frederick Kuhn, M.D.Savannah, GA

Introduction: Cultures taken from purulent sinus secretions in patients withchronic rhinosinusitis (CRS) often grow fungi. The purpose ofthis study is to report the isolates of fungal cultures in a largepatient population and do determine if these isolates differ inpatients with and without allergic fungal sinusitis (AFS).

Methods: Retrospective review of 10 years of 723 positive fungal cul-tures in 231 patients with CRS. Fungal genus and species, thenumber of positive cultures per patient, and location of thesamples were recorded. Patients were stratified into thosewith AFS and without AFS. The frequencies of fungal genusbetween groups were analyzed with chi-squared analysis.

78

Results: 723 positive fungal cultures were identified in 231 patients. Themost common encountered genera in order were Aspergillusfollowed by Curvularia, Pencillium, Alternaria, Bipolaris andFusarium. Each patient averaged 3.4 positive cultures. Themost common location of positive culture was the maxillarysinus. AFS was identified in 42. Those with AFS had signifi-cantly more positive cultures (P = 0.01) averaging 5.2 (CI:3.4,7.1) per patient compared to those without AFS 2.5 (CI:1.8, 3.2) positive cultures. Chi-squared analysis revealed a sig-nificant difference in the frequency of Aspergillus occurring inthose with AFS compared to those without (P = <0.05).However, there was no significant difference in the occurrenceof the other most commonly encountered genera in those withor without AFS.

Conclusion: A variety of fungal genera are found in purulent sinus secre-tions in patients with CRS. This study reports the frequency ofthese fungi and suggests that Aspergillus plays a more signifi-cant role in AFS vs. non-AFS patients.

#120 Practical Reduction of the Bulky Inferior TurbinateAndrew Lerrick, M.D., Alexis Mandli, PA-C Chicago, IL

Introduction:Inferior turbinate bones vary in size and shape. Most turbinatesare pedunculated and easily permit partial resection usingeither a Â”submucosalÂ” or Â”en-blocÂ” technique. Oneanatomic variant is the bulky turbinate, which, due to develop-mental, traumatic, or disease conditions, becomes hypertrophicfrom base to apex. In this instance, turbinate reduction utilizingboth techniques is effective.

Background: The medial aspect of the pedunculated turbinate is bulbous,the neck is narrow, and the base widens slightly to anchor it tothe lateral nasal wall. Turbinates with this profile easily permitmedialization and lateralization maneuvers. The bulky turbinateis diffusely hypertrophic, having a bulbous medial contour, wideneck, and broad base. This structure is far less amenable tomanipulation and requires significant bone reduction to changeits contour. Methods: Â ”Submucosal resection” is more difficult

79

to perform on the bulky turbinate. In the absence of a narrowneck, flap elevation is tedious, bleeding increases, and theflaps more apt to tear. Extensive bone debridement causesmore bleeding, necessitating additional cautery. With ”en-bloc”resection, after medialization a straight clamp is applied alongthe length of the inferior turbinate to demarcate the desiredamount of bone and soft-tissue to be removed. The peduncu-lated turbinate is amenable to these maneuvers, whereas thebulky turbinate is not. Crimping and cutting the bone, debridingbone fragments, and achieving hemostasis is more difficult withthe bulky turbinate. Thermal damage is greater and more boneis exposed to intra-nasal pathogens. Our method combines amodified version of both techniques. Without requiring in-frac-turing, a narrow clamp is insinuated on each side of the anteri-or aspect of the turbinate. Following compression and release,bipolar cautery is applied, the bone is cut, and the clamp re-positioned further posteriorly. The steps are repeated until themedian segment had been removed. Submucosal flaps areelevated from the open medial aspect, the bone debrided toachieve the necessary reduction, and the flaps are re-posi-tioned and thermally sealed to the underlying turbinate remnantto avoid bone exposure.

Conclusion: Using the combined techniques of "submucosal resection" and"en-bloc" resection effective reduction of bulky inferior turbinatebones can be achieved while minimizing progressive post-operative bone loss.

#121 Role of Radiographic Imaging in the PreoperativeEvaluation of Adults Undergoing Septoplasty forNasalObstructionBruce Tan, M.D., Marc Dubin, M.D.Chicago, IL

Background: The septoplasty for correcting nasal septal deviation in patientssuffering primarily from nasal obstruction is a commonly per-formed surgery in clinical practice. CT scan imaging is not aroutine diagnostic modality in the pre-operative evaluation ofthese patients.

Methods: A retrospective review was performed evaluating the computed

80

tomography (CT) findings in adults undergoing septoplasty fornasal obstruction. Patients undergoing septoplasty in conjunc-tion with functional endoscopic sinus surger (FESS) for gener-alized chronic sinusitis or those who received a septoplasty forendoscopic access were specifically excluded. Radiographicfindings, patient demographic information, presenting symp-toms and pre-operative endoscopic findings were captured.

Results: Fourty-two patients were included in the study after failingmedical therapy for nasal obstruction. Concurrent radiographicpathology was present in 37 patients (82 %). Sixteen had evi-dence of mild sinusitis that responded to medical therapy. Tenhad (22%) concha bullosa of sufficient size to require surgicalreduction. Ten had mucoceles (22%).

Conclusions: Preoperative CT evaluation of patients undergoing septoplastyfor nasal obstruction adds valuable information that can affectsurgical planning. However, careful endoscopic evaluation canpredict the presence of a substantial number of these radi-ographic findings.

#122 Spontaneous CSF Fistula with EncephalocelePresenting as Severe Obstructive Sleep ApneaSivakumar Chinnadurai, M.D., Matthew Carlson, M.D., John Pallanch, M.D.Rochester, MN

Background: There is mounting evidence to suggest that a large percent ofpatients with spontaneous CSF leaks (SCSFL) represent avariant of Idiopathic Intracranial Hypertension (IIH) sharingidentical patient demographics and similar symptoms. Onepopular theory suggests that chronically elevated pulsatileCSF pressures may erode already thin regions of the skullbase leading to encephalocele formation and eventual CSFÂ"release valvingÂ". We present a case of a 32-year-old mor-bidly obese female who presented with refractory sleep apneaand was found to have a large, obstructing encephalocele anda CSF fistula.

Methods: Case report and review of the literature Results: A morbidly

81

obese 32-year-old female presented for evaluation of long-standing symptoms of nasal obstruction. On interview thepatient complained of increased daytime somnolence, 3 yearsof intermittent clear unilateral rhinorrhea and a 3-month historyof progressive anosmia. Radiologic evaluation revealed anempty sella and a 6cm encephalocele breaching the left cribri-form and lateral lamella. This occluded the nasopharynx anddisplaced the soft palate anteroinferiorly. Following endoscopictreatment of the encephalocele and skull base defect, the CSFrhinorrhea ceased, and the patientÂ's obstructive sleep apneaimproved greatly.

Conclusion: Patients at risk for SCSFL can be identified by certain histori-cal and radiologic indicators. These patients may be subject touncommon sequelae such as obstructive encephalocele in ourpatient.

#123 Surgical Anatomy of the Sphenoid Sinus, InternalCarotid Artery and Distances to Critical StructuresStephanie Joe, M.D., Ryan Vaughn, M.D., G. Michael Lemole, M.D.Chicago, IL

Introduction: The objective of this study was to analyze the relationshipbetween the pneumatization pattern of the sphenoid sinus,configuration of the internal carotid artery (ICA) as well as dis-tance between the sphenoid sinus ostia and the height fromthe hard palate to the sphenoid ostia.

Methods:Measurements between sinonasal and skull base structureswere taken using the navigation planning station and comput-ed tomography angiographic images reconstructed in threeplanes. The pneumatization pattern of the sphenoid sinus wasdetermined. The configuration of the ICA anatomy wasdescribed using the distance between carotid siphon as wellas the height of carotid columns from the inferior most flexionto the siphon. The sphenoidal inter-ostial distance was takenfrom the medial aspect and the height from hard palate wasmeasured from the inferior aspect of the ostia.

82

Results: Twenty-seven cases were reviewed. The average inter-ostialdistance was 12.04 mm (SD 5.6 mm). The average height fromthe hard palate to the sphenoid ostium was 34.3 mm (SD 4.9mm) on the right and 34.6 (SD 7.2 mm) on the left. The aver-age inter-carotid distance at the siphon was 16.7 mm (SD 3.2mm) and the average length of the carotid columns was 15.2mm (SD 4.6 mm). The peumatization pattern of the sphenoidsinus was sellar in 44%, post-sellar in 52% and pre-sellar in4%.

Conclusions: Knowledge of the relationships between critical anatomic struc-tures can be used by endoscopic skull base surgeons to recog-nize challenging anatomy and define a safe operative plan.

#124 Turbinate Reduction Utilizing Acoustic RhinometryAndrew Lerrick, M.D., Alexis Mandli, PA-C Chicago, IL

Introduction: Turbinate size can vary as a result of physiologic effects anddisease. Acoustic rhinometry measures nasal airway dimen-sions, providing a topographic display of the septal-turbinaterelationship. A better understanding of intra-nasal anatomy,prior to surgical intervention, assists the surgeon in performingturbinate reduction with greater accuracy.

Methods: Acoustic rhinometry provides quantitative measurements byemitting wide-band noise and digitally analyzing the incidentand reflected waves. Pre-operative intra-nasal dimensions areoptimally obtained in the pre-medicated, congested, anddecongested states to determine the baseline, soft tissue, andbony contributions to nasal airway obstruction, respectively.Allergic and non-allergic stimuli can be inhaled to trigger nasalcongestion. Injection of a vasoconstrictive agent determinesthe maximal potential pre-operative nasal airway, which is limit-ed by persistent bony barriers. Comparison can be madebetween the three physiologic conditions and standardizednorms of intra-nasal anatomy. Ideally, the septum is midlineand does not contribute to nasal obstruction. Turbinate-to-turbinate cross-sectional measurements can account for septaldeflections.

83

Results: Possessing knowledge of the contribution made by eachturbinate to nasal obstruction, selective removal of soft-tissueand boney resection of hypertrophic turbinates can beachieved. Intra-operative rhinometric measurements can beobtained to calculate the extent of turbinate reduction toachieve the desired result. Optimally, equal distances areestablished between the septum and the inferior and middleturbinates at the respective level of each.

Conclusion: Acoustic rhinometry provides data to gauge the degree towhich turbinate reduction is necessary to establish an ade-quate, symmetric nasal airway.

#125 Unilateral Epistaxis in a Middle Aged Man: A RarePresentation of Pyogenic GranulomaJason Champagne, M.D., Troy Woodard, M.D., Stilianos Kountakis, M.D. Augusta, GA

Introduction: Pyogenic granuloma most commonly involves oral mucosa butis also found on the skin or in the nasal cavity, especially thenasal septum. A disease classically described in children andyoung females, it is rarely found in men. We present a uniquecase of a large (5x8cm) unilateral nasal tumor, pyogenic granu-loma, arising from the middle turbinate in a middle-aged man.

Methods: Case report. High-resolution endoscopic, computed tomogra-phy (CT), and magnetic resonance (MR) images as well as his-tologic photomicrographs provide excellent characterizationand visualization of the lesion.

Results:A 42 year-old man presented with a two-month history of wors-ening nasal congestion, intermittent left-sided epistaxis, andthrobbing, retro-orbital pain. Previous medical therapy with topi-cal steroids and nasal saline did not relieve his symptoms.Nasal endoscopy revealed a highly vascularized, left-sidedmass filling the middle meatus and extending into thenasopharynx. CT and MR images demonstrated a left-sidedexpansile, soft tissue mass causing medial displacement of the

84

middle turbinate and lateral displacement of the medial maxil-lary sinus wall. Endoscopic excision after embolizationrevealed significant tissue fibrosis with the source of the lesionbeing the basal lamella of the left middle turbinate. Pyogenicgranuloma was reported on final pathologic diagnosis.Postoperative endoscopic examination showed no evidence ofresidual tumor, and the patient reported resolution of hissymptoms.

Conclusion: Pyogenic granuloma rarely presents in the male population,especially emanating from the middle meatus. This diseaseprocess should always be considered in oneÂ's differentialdiagnosis when a vascular nasal mass is encountered.

#126 Unrecognized Odontogenic Maxillary Sinusitis Â- ACause of Endoscopic Sinus Surgery FailureAnthony Longhini, BS, Berrylin Ferguson, M.D.Pittsburgh, PA

Background: Endoscopic sinus surgery (ESS) is reported to improve symp-toms in approximately 85% of patients. Reasons for failureinclude misdiagnosis, technical inadequacies, underlying severehyperplastic disease, biofilm and immunodeficiency. We areunaware of literature citing unrecognized dental etiology as areason for failure to improve with sinus surgery. Aim: To charac-terize clinical and radiographic findings in patients who fail toimprove with ESS because of unrecognized dental etiology.

Design: Prospective enrollment of patients with odontogenic maxillarysinusitis with prior endoscopic sinus surgery. Patients: 5 adultswith odontogenic maxillary sinusitis and unsucessful ESS.Intervention: Demographics, and clinical aspects includingduration of illness, prior sinus surgeries and therapies andradiographic data were assessed.

Results: 5 adults underwent an average of 2.6 ESSs with persistenceof disease and symptoms until their dental infection was treat-ed. Duration of symptoms ranged from 1 to 15 years. In 4 of 5patients, the periapical abscess was not noted on the CT

85

report. Three of 5 patients had been seen by their dentists andtold they had no dental pathology. With treatment of the dentalabscess, symptoms in all patients resolved.

Conclusion: Unrecognized periapical abscess is a cause of ESS failureand frequently the radiographic report will fail to note the peri-apical infection. Dentists are unable to recognize periapicalabscesses reliably with dental x rays and exam. In patientswith CT maxillary sinus disease, the teeth should be specifical-ly examined.

#126 Zygomaticomaxillary Mucocele with ConcomitantFrontoethmoid Mucocele Presenting Four Decades afterFacial TraumaBenjamin Powell, M.D., Patrick Munson, M.D., John Pallanch, M.D. Rochester, MN

Paranasal sinus mucoceles are most frequently found involv-ing the frontal sinuses, but are also often found involving theethmoid, maxillary, and more rarely, the sphenoid sinuses.Involvement of the zygomatic bone by a mucocele is extreme-ly rare, with only one reported case in humans found in the lit-erature. This presentation shows the imaging and videofootage of a 49 year old male who was found to have concur-rent zygomaticomaxillary and frontal sinus expansile mucoce-les. He presented with facial pain and headache, with no his-tory of sinusitis, but facial trauma to the area several decadespreviously. A transmaxillary endoscopic approach to the zygo-matic mucocele was undertaken. The extensive frontoethmoidmucocele was approached with combined transnasal endo-scopic sinus surgery and frontal sinus trephination. Pre andpost operative radiographic images as well as intraoperativevideo footage and imaging will be utilized to discuss the pres-entation, evaluation, and treatment of this common lesion in arare location.

86

Dr. Maurice H. Cottle Honor Award

For Outstanding Clinical and Laboratory Incestigation inRhinology

First Place Gold Medal Winners

1978The Nasal Cycle in the Laboratory AnimalWinston M. Campbell, MD, Mayo Clinic, Rochester, MNEugene B. Kern, MD, Mayo Clinic, Rochester, MN

1979The Physiologic Regulation of Nasal Airway ResistanceDuring Hypoxia and HypercapniaT.V. McCaffrey, MD, Mayo Clinic, Rochester, MNEugene B. Kern, M.D., Mayo Clinic, Rochester, MN

1980 (Two Awards Given)Growth Patters of the Rabbit Nasal Bone Region - ACombined Serial Gross Radiographic Study with MetallicImplantsBernard C. Sarnat, MD, Los Angeles, CAAbbee Selman, DDS, Los Angeles, CA

Sleep Disturbances Secondary to Nasal ObstructionKerry D. Olsen, MD, Mayo Clinic, Rochester, MNEugene B. Kern, MD, Mayo Clinic, Rochester, MNPhillip R. Westbrook, MD, Mayo Clinic, Rochester, MN

1984Nasal Problems in Wood Furniture Workers-A Study ofSymptoms and Physiological VariablesBorje Drettner, MD, SwedenBo Wihlelnisson, MD, Sweden

1987Eustachian Tube and Nasal Function During Pregnancy -A Prosepective StudyCraig S. Derkay, MD, Pittsburgh, PA

87

1988The Effects of Kiebsiella Ozenae on Ciliary Activity inVitro: Implications for Atrophic RhinitisJonathan Ferguson, MD, Mayo Clinic, Rochester, MN

1990The in Vivo and in Vitro Effect in Phnylephirine (NeoSynephrine) on Nasal Ciliary Beat Frequency andMucoolliary TransportP. Perry Phillips, MD, Mayo Clinic, Rochester, MN

1991Ultrastructural Changes in the Olfactory Epithelium inAlzheimer’s DiseaseBruce Jafek, MD, University of Colorado, Denver, CO

1992A Scanning Electron Microscopic Study of Msoking andAge Related Changes in Human Nasal EpitheliumSteven Kushnick, MD, New York, NY

1993Mucociliary Functionin Endothelins 1, 2 & 3Finn Ambie, MD, Mayo Clinic, Rochester, MN

1996Capsacin's Effect on Rat Nasal Mucosa Substance PReleaseFrederick A. Kuhn, MD, Savannah, GA

1999Subacute Effects of Ozone-Exposure on CultivatedHuman Respiratory MucosaJoseph Gosepath, MD, D. Schaefer, MD, C. Broomer, MD, L. Klimek, MD, R.G. Amedee, MD, W.J. Mann, MD, Mainz, Germany

2000Capsacin's Effect on Trigenonal Nuciens Substance PReleaseFrederick A. Kuhn, MD, Savannah, GA

88

2002Bioengineering of Cartilage Using Human NasalChondrocytes Propagated in Microcarrier Spinner CultureAlan H. Shikani, MD, David J. Fink, Ph.D., Afshin Sohrabi,M.H.S., Phong Phan, BS, Anna Polotsky, MD, David S.Hungerford, MD, Carmelita G. Frondoza, Ph.D, San Diego, CA

2004Composition Of Hyaluronan Affects Wound Healing In TheRabbit Maxillary Sinus Matthew Proctor, M.D., Kery Proctor, M.D., Xian Zheng Shu,PhD., L.D. McGill, DVM, PhD., Glenn D. Prestwich, PhD.,Richard R. Orlandi, M.D.

2005Acoustic Rhinomotry Predicts Tolerance of NasalContinuous Positive Airway Pressure (nCPAP): A PilotStudy.Luc G. Morris, MD, Jennifer Setlur, BS, Omar E. Burschtin,MD, David L. Steward, MD, Joseph B. Jacobs, MD, Kelvin C.Lee, MD

2006Reversal of Chronic Rhinosinusitis Associated SinonasalCiliary DysfunctionBei Chen, MD, Marcelo B. Antunes, MD, Steven Eau Claire,James Plamer, MD, Alexander Chiu, MD, David W. Kennedy,MD, Noam Cohen, MD, Ph.D.

2007Reversible Olfactory Loss Due to Inflammation in aTransgenic Mouse ModelAndrew Lane, M.D., Justin Turner, M.D., Lindsey May, BS,Randall Reed, PhD.

89

Golden Head Mirror Honor Award ForMeritorious Teaching in Rhinology

The Golden Head Mirror Honor Award was first givenby Dr. Maurice Cottle to colleagues who were chosenbecause of “Meritorious Teaching in Rhinology”. Thefirst pair of Golden Head Mirror Cuff Links was givenby Dr. Cottle to Dr. George Fisher in 1948.

AVijay Anand, USPierre Arbour, USHarold Arlen, USWalter J. Aagesen, USTomas L. Aguara, Mexico

BPat A. Barelli, USFred W. Beck, US*Carlos G. Benavidee, USMichael Benninger, USBernard Blomfield, US*Max Bornstein, US*

CJamie Carillo, Mexico*James Chessen, US*Maurice H. Cottle, US*

DEfrain Davalos, MexicoH.A.E. van Dishoeck, TheNetherlands*George H. Drumheller, US*Glen W. Drumheller, USLarry E. Duberstein, US

FGeorge W. Facer, USAnthony Faills, US*George G. Fisher, US*Douglas W. Frericha, USAmos D. Friend, US*

GIrwin E. Ganor, USNorman E. Ginsberg, US*VernonD. Gray, US*Charles Gross, USHarvey C. Gunderson, US

HJames A. Hadley, MDRichard B. Hadley, US*Robert M. Hansen, US*Edward W. Harris, US*Raymond L. Hilsinger, US*Kenneth H. Hinderer, US*Leland R. House, USSandy Hoffman, USEgbert Huizing, TheNetherlands

JGerald F. Joseph, USJoseph B. Jacobs, MD

90

KAlvin Katz, USDavid Kennedy, USEugene Kern, USJohn Kirchner, USDaniel D. Klaff, US*Zvonimir Krajina, CroatiaFrederick A. Kuhn, US

LClifford F. Lake, US*Donald Lanza, USDonald Leopold, USWalter E.E. Loch, US*W. Kaye Lochlin, USFausto Lopez-Infante,MexicoRoland M. Loring, US*Frank Lucente, US

MHenry Merriman, US*Lewis E. Morrison, US

NWilliam J. Neidlinger, US*Roberto Nevews-Pinto,BrazilLeon Neiman, US

OJoseph H. Ogura, US*Harold Owens, US

PCharles J. Patrillo, US*Ivan W. Philpott, US*Loring W. Pratt, US

RFrederico Reyes, MexicoRalph H. Riggs, USZvi Henry Rosen, Israel

SPiefer H. Schmidt, TheNetherlandsThomas C. Smersh, USMaynard P. Smith, USPinckney W. Snelling, US*Carl B. Sputh, USHeinz Stammberger, AustriaAlbert Steiner, US*Sydney L. Stevens, US*Fred Stucker, USGiorgio Sulsenti, ItalyEdward A. Swartz, US

TWilliam H. Tenny, USH. Ashton Thomas, US*Paul H. Toffel, USRichard Trevino, USCharles A. Tucker, US

WRichard C. Webster, US*Alvin P. Wenger, USJoseph W. West, US*Manual R. Wexter, US*Henry L. Williams, US*Russell I. Williams, US

* Deceased

91

New Investigator Award — (CORE)

2009Novel Flavonoid Compounds for Cystic Fibrosis ChronicRhinosinusitisBradford Woodworth, MD

Mucin expression in Paranasal Respiratory Epithelium CellCultureDavid Poetker, MD

2008The Role of Epithelial Cells in Chronic Rhinosinusitis withNasal PolypsBradley Otto, MD

2007Regulatory T Cells in Chronic RhinosinusitisJayant Pinto, MD

2006Efficacy of Topical Lactoferrin and Antibiotics in an AnimalModel of SinusitisAlexander Chiu, MD

2005Surfactant Proteins A and D In Chronic SinusitisRodney J. Schlosser, MD

2004Assessment of Bacterial Biofilms in SinusitisJames N. Palmer, M.D.

2002Characterization of Eosinophil Peroxidase-Induced TissueDamage in Sinonasal Polyposis and Chronic RhinosinusitisMartin J. Citardi, MD

Influence of Estrogen on Maturation of Olfactory NeuronsKaren J. Fong, MD

2001Apoptosis in the Aging Olfactory MucosaDavid B. Conley, MD

92

Clinical Science Research Award2007 (COSM)Demonstration of Biofilms in Chronic Sinusitis UsingLight MicroscopyA. Bhatki, M.D., A. Goldberg, M.D., M. Gangar, M.D., G.Hradek, M.S.

2006 (COSM)Impact of Depression on Disease-Specific Symptoms andQuality of Life in Patients with Chronic RhinosinusitisRebecca Bransted, MD

Basic Science Research Award2009 (Annual Meeting)(Production of this abstract book was completed prior to theselection of the awardees)

2008 (Annual Meeting)Interleukin 1 Receptor-like 1 Gene is Associated withChronic RhinosinusitisRoberto Castano, MD, Yohan osse, MD, Leandra Mfuna, MD,Martin Desrosiers, MD

2008 (Annual Meeting)Olfactory Function and Disease Severity in ChronicRhinosinusitisJamie Litvack, MD, Jess Mace, MPH, Kenneth James, PhD,Timothy Smith, MD

2008 (COSM)Reversible Loss of Neuronal Marker Protein Expression ina Transgenic Mouse Model for Sinusitis-associatedOlfactory DysfunctionJustin Turner, MD, PHD, Lindsey May, BS, Randall Reed,PhD., Andrew Lane, MD

2007 (COSM)Methods for Removing Bacterial Biofilms: In Vitro StudyUsing Clinical Chronic Rhinosinusitis SpecimensMartin Desrosiers, M.D., M. Myntti, Ph.D., G. James, Ph.D.

93

International Research Award

2006 (COSM)Chronic Rhinosinusitis with Nasal Polyps is Associatedwith Decreased Expression of Epithelial Interleukin 22ReceptorMurugappan Ramanathan, Jr., MD

2005Altered Expression Of Genes Associated With InnateImmunity In Recalcitrant Rhinosinusitis With Polyps. Andrew P. Lane, M.D.2004Superantigens and Chronic Sinusitis II: Analysis of T CellReceptor VB Domain in Nasal PolypsDavid B. Conley, MD, Anju Tripathi, MD, Kristin A. Seiberling,MD, Leslie C. Grammar, MD, Robert C. Kern, MD

2003Nitric Oxide and Collagen Expression in Allergic UpperAirway DiseaseMarc A. Tewfik, CSc, Julio F. Bernardes, MD, Jichaun Shan,MD, Michelle Robinson, BSc, Saul Frenkiel, MD, David H.Eidelman, MD

2000An Animal Model for Allergic Fungal SinusitisFelicia Grisham, MD

Histologic Study of the Superior TurbinateDonald Leopold, MD

2009(Production of this abstract book was completed prior to theselection of the awardees)

2008Development of a Low Cost Endoscopic Sinus SurgicalTrainerRandy M. Leung, MD, Jerry M. Leung, MD, Adam Dubrowski,PhD, Ian Witterick, MDToronto, Canada

94

2006Effectiveness of Topical Antibiotics on StaphylococcusAureus Biofilm in VitroMartin Desrosiers, MD, Zohra Bendouah, Msc., Jean Barbeau,Ph.D

A Sheep Model for the Study of Biofilms in Rhinosinusitis Kien R. Ha, MBBS, Alkis J. Psaltis, MBBS, Lorwai Tan, Ph.D,Peter John Wormald, MD

2005Brain Perfusion SPECT Findings in Patients withPosttraumatic Anosmia and Comparison withRadiological Imaging Mohammad Eftekhari, Majid Assadi, Majid Kazemi, MohsenNaraghi, Jalal Mehdizadeh, Mohsen Saghari, AlirezaMojtahedi, Mohammad Sadeghi-Hasamabadi, Armagan Fard-Esfahani, Babak Fallahi, Davood Beiki

2004Development of A Rhinovirus Study Model Using OrganCulture of Turbinate Mucosa Yong Ju Jang, M.D., Si Hyeong Lee, M.D., Hyon-Ja Kwon,MSc, Yoo-Sam Chung,M.D., Bong-Jae Lee, M.D.

2003Nitric Oxide and Collagen Expression in Allergic UpperAirway DiseaseMarc A. Tewfik, MD, Julio F. Bernardes, MD, Jichuan Shan,MD, Michelle Robinson, MD, Saul Frenkiel, MD, David H.Edelman, MD

2002Recording of the Electro-Olfactogram (EOG) UsingExternally Placed ElectrodesChurunal K. Hari, F.R.C.S., Liwei Wang, Ph.D, Tim J.C. Jacob, Ph.D, San Diego, CA

95

2009(Production of this abstract book was completed prior to theselection of the awardees)

2008Management of Sinonasal Malignant Neoplasms: Definingthe Role of EndoscopyAmber Luong, MD

CT Scan Severity Correlates with Improvement in Qualityof Life Outcomes after Endoscopic Sinus Surgery inPatients with Chronic Rhinosinusitis and AsthmaPatricia Maeso, MD

Resident/Fellows in Training TravelGrant

96

Affiliate MembersMichael J Chandler, MDNew York, NY

Bernard Feigenbaum, MDNew York, NY

Joshua Makower, MDMenlo Park, CA

Jeffrey Schroeter, Ph.DResearch Triangle Park, NC

Wellington Tichenor, MDNew York, NY

ResidentMembersArman Abdalkhani, MDPalo Alto, CA

Zahi Abou Chacra, MDMontreal, Canada

Nithin Adappa, MDNew York, NY

Chad Afman, MDCincinnati, OH

Nadir Ahmad, MDBirmingham, MI

Lee Michael Akst, MDMaywool, IL

Talal A. Alandejani, MDVancouver, BC

John W. Alldredge, MDChapel Hill, NC

Phillip G Allen, MDAlbany, GA

Yaser Alrajhi, MDVerdun, QC

Bryan Thomas Ambro, MDBaltimore, MD

Manali S. Amin, MDBoston, MA

Scott Anderson, MDNorfolk, VA

Amy Anstead, MDChicago, IL

Jastin L Antisdel, MDSt Louis, MO

Matthew Ashbach, MDNew York, NY

Sumit Bapna, MDColumbus, OH

Lucy J Barr, MDSalt Lake City, UT

Steven W. Barthel, MDBellevue, WA

Benjamin A Bassichis, MDDallas, TX

Rami Kamal Batniji, MDNewport Beach, CA

Garrett H. Bennett, MDNew York, New York

Eric Berg, MDAtlanta, GA

97

Richard T. Bergstrom, MDRedding, CA

Salim S. Bhaloo, MDMadison Heights, MI

Naveen Bhandarkar, MDPortland, OR

Alexander G Bien, MDOmaha, NE

Benjamin S Bleier, MDCharleston, SC

Darius Bliznikas, MDRoyal Oak, CA

David Bradley Bobbitt, MDCincinnati, OH

Michiel Bove, MDChicago, IL

Rebecca Brandsted, MDSt. Louis, MO

Aaron I. Brescia, MDCincinnati, OH

Russell Deane Briggs, MDWinter Haven, FL

John M Brockenbrough, MDUrbana, IL

Laura Devereux Brown, MDRaleigh, NC

Edward D Buckingham, MDGalveston, TX

Matthew Bush, MDLexington, KY

Henry Frederick Butehorn Jr., MDSpartanburg, SC

Allen PS Butler, MDEunice, LA

Sydney C Butts, MDSyracuse, NY

Tracey Byerly, MDHouston, TX

Benjamin B. Cable, MDKailua, HI

Emiro Caicedo-Granados, MDPittsburgh, PA

Gerard Carvalho, MDHemet, CA

Jon Blake Chadwell, MDEdgewood, KY

Jeffrey Chain, MDDenver, CO

Vincent T Chan, MDSeattle, WA

Yvonne Chan, MDMississauga, Ontario

Stephen William Chandler, MDMontgomery, AL

Binoy Chandy, MDMuncie, IN

David B. Chapman, MDWinston Salem, NC

Daniel Charous, MDPhoenix, AZ

Judy L. Chen, MDStanford, CA

Margaret A. Chen, MDSan Diego, CA

98

Sri K. Chennupati, MDPhiladelphia, PA

Scott Kevin Chiang, MDPalo Alto, CA

Michael Cho, MDMission Viejo, CA

Kyle S Choe, MDVirginia Beach, VA

Nathan Christensen, MDRochester, NY

Kim Christopher, MDSunnyvale, CA

Brian Chung, MDCleveland Hts, OH

Sung J Chung, MDJoilet, IL

David Clark, MDHouston, TX

Lindsey Clemsor, MDAtlanta, GA

Alen N Cohen, MDLos Angeles, CA

C. Michael Collins, MDCincinnati, OH

James Lapeyre Connolly, MDDestin, FL

J. Matthew Conoyer, MDSt. Peters, MO

Anthony J Cornetta, MDHuntington Station, NY

Catherine A Craig, MDOmaha, NE

Jason Cundiff, MDChicago, IL

Linda D Dahl, MDNew York, NY

Myra Danish, MDWest Bloomfield, MI

George Stephen Dawson, MDCharleston, WV

Indranil Debnath, MDSaint Louis, MO

Michael E Decherd, MDSan Antonio, TX

David Denman, MDOmaha, NE

Brad deSilva, MDGalloway, OH

Jason A Diaz, MDSalt Lake City, UT

Paul A DiBiase Jr, MDSteubenville, OH

William Oliver Dickey, MDParker, CO

E. Nicholas Brannan Digges, MDOklahoma City, OK

Venu Divi, MDDetroit, MI

Joni Kristin Doherty, MDSan Diego, CA

David Donaldson, MDPoatello, ID

Alexander Stephen Donath, MDSt. Louis, MO

99

Jayme Dowdall, MDRoyal Oak, MI

Aaron J Duberstein, MDDetroit, MI

Marika R. Dubin, MDSan Francisco, CA

Praveen Duggal, MDAtlanta, GA

Wilson Dumornay, MDBronx, NY

Frederick Durden, MDMabelton, GA

Rose Eapen, MDDurham, NC

Emily E. Epstein, MDSt. Louis, MO

Victoria Epstein, MDNew York, IL

Vanessa R Erickson, MDMenlo Park, CA

Joshua Espelund, MDOmaha, NE

Michelle Lee Facer, MDEau Claire, WI

Patrick C. Farrell, MDOmaha, NE

James C. French, Jr., MDAlpharetta, GA

Oren Friedman, MDPhiladelphia, PA

Michael A. Fritz, MDCleveland, OH

Beverly Claire Fulcher, MDJackson, MS

Wendy Funk, MDFarmington, CT

Chad Galer, MDBellaire, TX

Suzanne Kim Doud Galli, MDReston, VA

Courtney West Garrett, MDReno, NV

John Gavin, MDAlbany, NY

Yuri Gelfand, MDHouston, TX

Bobak Ghaheri, MDPortland, OR

Mark Ghegan, MDMt. Pleasant, SC

Michelle S. Ghostine, MDRedlands, CA

Michael Erik Gilbert, MDPost Falls, ID

Matthew D Gillihan, MDLas Cruces, NM

Michael B. Gluth, MDSpringdale, AR

Fernando Gomez-Rivera, MDHouston, TX

Gabrielle Goncalves, MDBrazil

Omar A. Gonzales-Yanes, MDPuerto Rico

100

Quinton Gopen, MDWeston, MA

Joshua Adam Gottschall, MDOakland, CA

Jennifer Grady, MDFarmington, CT

William Grambrell, MDLouisville, KY

Felicia J Grisham, MDNashville, TN

Eli R. Groppo, MDSan Francisco, CA

Neil D. Gross, MDPortland, OR

Samuel Paul Gubbels, MDIowa City, IA

Justin Gull, MDFarmington, CT

Akash Gupta, MDColumbus, OH

Theresa A. Gurney, MDSan Francisco, CA

Trevor Hackman, MDPittsburgh, PA

Jahmal Hairston, MDDouglasville, GA

Nathan Hales, MDOklahoma City, OK

Christopher M Hampson, MDWinfield, IL

Christopher A Hargunani, MDPortland, OR

Kevin C. Harris, MDMount Vernon, WA

Thorsen W. Haugen, MDDanville, PA

Matthew Hearst, MDCincinnati, OH

Ryan Heffelfinger, MDPhiladelphia, PA

Oswaldo A. Henriquez, MDAtlanta, GA

Brian Herr, MDFort Wayne, NJ

Stephanie Herrera, MDHouston, TX

Derek K Hewitt, MDColumbia, MO

Kimberly Michelle Hewitt, MDSalt Lake City, UT

Thomas Higgins, MDNorfolk, VA

Gerhard Hill, MDFarmington, CT

Micah Hill, MDWoodside, CA

Samuel Lane Hill III, MDMaples, FL

Allen S Ho, MDMountain View, CA

Neil Hockstein, MDWilmington, DE

Michael Hopfenspirger, MDMinneapolis, MN

101

Nelson Scott Howard, MDSilver Spring, MD

Raymond Howard, MDRome, GA

Anna P. Hsu, MDLos Angeles, CA

Kevin G. Hueman, MDSan Antoio, TX

Kevin J Hulett, MDWinfield, IL

Shannon Elizabeth Hunter, MDClyde, NC

Keith Hurvitz, MDLos Angeles, CA

Harry S. Hwang, MDSan Francisco, CA

William Innis, MDBoston, MA

Masatuki Inouye, MDHackensack, NJ

Stacey Lynn Ishman, MDBaltimore, MD

Chandra Ivey, MDNew York, NY

Ofer Jacobowitz, MD PhDMiddletown, NY

Sonu Abhishek Jain, MDBurlington, MA

Gina Jefferson, MDRiverside, CA

Kenneth L Johnson, MDBirmingham, AL

Madan N. Kandula, MDMilwaukee, WI

Brian A. Kaplan, MDTowson, MD

Elina Kari, MDAtlanta, GA

Andrew Nicholas Karpenko, MDMonroe, MI

Scott M, Kaszuba, MDHouston, TX

Katherine Kavanagh, MDFarmington, CT

Srinivas R Kaza, MDCanandaigua, NY

Mark L. Keller, MDHastings, NE

Thomas Kelly, MDTroy, MI

Manish Khanna, MDSunnyvale, CA

John D. Kilde, MDAlbermarle, NC

Christopher Jinsup Kim, MDVacaville, CA

Esther Kim, MDBethesda, MD

Eugene Kim, MDSan Francisco, CA

Eugene Joseph Kim, MDMountain View, CA

Seungwon Kim, MDSyracuse, NY

102

Sihun Alex Kim, MDWoodstock, IL

Theresa B. Kim, MDSan Francisco, CA

Robert E King, MDRome, GA

Michael J Kortbus, MDRhinebeck, NY

Clinton Kuwada, MDFarmington, CT

Christina J Laane, MDRedwood City, CA

Devyani Lal, MDPalo Alto, CA

Babak Larian, MDLos Angeles, CA

Alenna B. Laxton, MDCincinnati, OH

Bich Thuy Le, MDNew York, NY

Bryan D Leatherman, MDGulfport, MS

Annie Lee, MDSt. Petersburgh, FL

Jivianne Lee, MDLos Angeles, CA

Walter Lee, MDCleveland, OH

Grace Leu, MDAtlanta, GA

Man-Kit Leung, MDBoston, MA

Jonathan Marc Levine, MDWest Nyack, NY

Karen Lin, MDSeattle, WA

Jonathan P Lindman, MDDothan, AL

David Litman, MDCumberland, MD

Jamie R. Litvack, MDPortland, OR

Kevin W. Lollar, MDColumbia, MO

Manuel Lopez, MDSan Antonio, TX

Robert R Lorenz, MDCleveland, OH

Amber Luong, MD, PhDHouston, TX

Li-Xing Man, MDPittsburgh, PA

Peter Manes, MDWashington, DC

Lance Anthony Manning, MDSpringdale, AR

Kyle Mannion, MDFarmington, CT

Belinda A Mantle, MDFairfax, VA

Osama Marglani, MDRichmond, BC

Adam Mariotti, MDMaywood, IL

103

Darby D Marshall, MDScottsboro, AL

Paul A Martin, MDVallejo, CA

Casey Mathison, MDAtlanta, GA

Steve Maturo, MDSan Antonio, TX

Peter F Maurice III, MDSeattle, WA

Kate E. McCarn, MDPortland, OR

Clement Joseph McDonald,MDIndianapolis, IN

James Wesley McIlwaine, MDSt. Louis, MO

Lee Ann McLaughlin, MDNew York, NY

Sean M McWilliams, MDDestin, Fl

Cem Meco, MDAnkara, Turkey

Nicholas Mehta, MDCincinnati, OH

Matthew Montgomery Meigs, MDTampa, FL

Jeremy S Melker, MDGainesville, FL

Jonathan Wade Mellema, MDWillmar, MN

George A. Melnik, MDValparaiso, IN

Christopher Melroy, MDSavannah, GA

Tanya Kim Meyer, MDBaltimore, MD

Oleg N Militsakh, MDCharleston, SC

Brian T Miller, MDSalt Lake, NY

Robert Sean Miller, MDSt. Augustine, FL

Timothy R Miller, MDSan Clemente, CA

Ryan Mitchell, MDPontiac, MI

Ashkan Monfared, MDPalo Alto, CA

William Moretz, MDAugusta, GA

Luc GT Morris, MDNew York, NY

Christopher D Muller, MDClearwater, FL

Karsten Munck, MDTravis AFB, CA

Srikanth I Naidu, MDCordova, TN

Mandana Namiranian, MDChicago, IL

Iman Naseri, MDJacksonville, FL

Jeffrey Nau, MDLouisville, KY

104

Michael Edward Navalta, MDQuezon City, Manila

Brian A. Neff, MDRochester, MN

Marc Nelson, MDHudson, Oh

Chau T. Nguyen, MDVentura, CA

Hoa Van Nguyen, DOCalumet City, IL

Nghia Nguyen, MDDetroit, MI

Ajani Nugent, MDScottsdale, GA

Gurston G Nyquist, MDEmeryville, CA

Timothy O'Brien, MDFarmington, CT

Thomas R O'Donnell, MDBay Shore, NY

Bradley A Otto, MDPittsburgh, PA

Thomas Ow, MDBronx, NY

Kevin S. Oxley, MDMorgatown, WV

Matthew P Page, MDColumbia, MO

Sachin S. Parikh, MDStanford, CA

Shatul Parikh, MDSmyrna, GA

Samual R. Pate, MDOmaha, NE

Andrew Patel, MDSan Diego, CA

Ankit Patel, MDJoliet, IL

Renee Penn, MDWashington, DC

Donald Perez, MDLoma Linda, CA

Joel R Perloff, MDChester, PA

Timothy Pine, MDReno, NV

Jayant M Pinto, MDChicago, IL

Jonathan Pomerantz, MDChicago, L

Glen Porter, MDNorth Las Vegas, NV

Scott A. Powell, MDTampa, FL

Matthew David Proctor, MDIowa City, IA

Liana Puscas, MDDurham, NC

Vijay Ramakrishnan, MDAurora, CO

Alexander L. Ramirez, MDSalinas, CA

Jeff Rastatter, MDColumbus, OH

105

Jacquelyn Reilly, MDHyannis, MA

Sara Retsema, MDChicago, IL

Dukhee Rhee, MDEverett, MA

Brynn E Richardson, MDOmaha, NE

Yvonne Richardson, MDFarmington, CT

Jeremy David Richmon, MDSan Diego, CA

Anthony Allan Rieder, MDMilwaukee, WI

Tamara Rimash, MDSt. Albans, VT

Nabil M. Rizk, MDEgypt

Matt Robertson, MDFort Collins, CO

Ashley B Robey, MDOmaha, NE

Bret J. Rodgers, MDBoise, ID

Krista M. Rodriguez-Bruno, MDSan Francisco, CA

Frederick Roediger, MDSan Francisco, CA

Gamwell Rogers, MDAtlanta, GA

Alexander A Romashko, MDEl Grove, IL

Walter Rooney, MDCincinnati, OH

David B. Rosenberg, MDNew York, NY

Joshua Rosenberg, MDBronx, NY

Joshua M Rosenthal, MDNesconset, NY

Laura H Rosenthal, MDDetroit, MI

Marc Rosenthal, MDSicklerville, NJ

Adam T. Ross, MDCharleston, SC

Luke R Rudmik, MDCalgary, Alberta, Canada

Justin B Rufener, MDDetroit, MI

Matthew S. Russell, MDSan Francisco, CA

John M Ryzenman, MDNew Albany, OH

Bassem M. Said, MDBrentwood, CA

David M. Saito, MDSan Francisco, CA

Frank Salamone, MDRochester, NY

Sharyar Samadi, MDPhiladelphia, PA

Ruwanthi Samaranayake, MDAlameda, CA

106

Sreeedhar Samudrala, MDJackson, MS

Kenneth Sanders, MDDallas, TX

Alicia R Sanderson, MDSan Diego, CA

Jan Sasama, MDBerlin, Germany

Nathan Sautter, MDPortland, OR

Christopher Savage, MDCincinnati, OH

Victor Scapa, MDAurora, CO

Paul Schalch, MDTustin, CA

Joseph Scharpf, MDCleveland, OH

Sara C Scheid, MDAlbany, NY

Michael Scheuller, MDOgden, UT

Jeffrey Schmidt, MDOmaha, NE

Stacey L Schulze, MDMilwaukee, WI

Heather Rose Schwartzbauer,MDOlney, MD

Joseph M Scianna, MDSycamore, IL

Paul Scolieri, MDBethel Park, PA

Matthew T Sdano, MDBeloit, WI

Brook Matthew Seeley, MDFarmington, CT

Kristin A Seiberling, M.D.Chicago, IL

Rahul Seth, MDCleveland, OH

Anita Sethna, MDAtlanta, GA

Jennifer Setlur, MDSyracuse, NY

Ryan K Sewell, MDOmaha, NE

Anand Gopal Shah, MDMarietta, GA

Maulik B. Shah, MDBronx, NY

Shefali Shah, MDLong Beach, NY

Weiru Shao, MDBoston, MA

Samuel Gardner Shiley, MDPortland, OR

Lisa Shnayder, MDFair Lawn, NJ

Michel Siegel, MDHouston, TX

Jason B Sigmon, MDOklahoma City, OK

Damon A. Silverman, MDBurlington, VT

107

John Sinacori, MDNorfolk, VA

James Andrew Sipp, MDAtlanta, GA

Eric Slattery, MDSt. Louis, MO

Dana Sainsbury Smith, MDClackamas, OR

Ronald M Smith, MDSpringfield, OH

Mary C. Snyder, MDOmaha, NE

Clementino Solares, MDCleveland, OH

Thomas C Spalla, MDDetroit, MI

Andrew Spector, MDManchester, NH

Jacob D. Steiger, MDPhiladelphia, PA

Jeannine Stein, MDCleveland, Oh

Alexander E. Stewart, MDNorth Charleston, SC

Thomas A Stewart, MDLoma Linda, CA

Howard D Stupak, MDHaden, CT

Jeffrey Suh, MDPhiladelphia, PA

Sarmela Sunder, MDStanford, CA

Maria Suurna, MDCincinnati, OH

Gregory Swanson, MDAppleton, WI

Monica Tadros, MDNew York, NY

Su Wooi Teoh, MDIndianapolis, IN

Belachew Tessema, MDNew York, NY

Marc A. Tewfik, MDMontreal Quebec

Wyatt C To, MDFrederick, MD

Vincent Sabah Toma, MDToledo, OH

Jairo Torres, MDCleveland Heights, OH

Corey Treadway, MDDearborn, MI

Betty S. Tsai, MDSan Francisco, CA

Anthony Tucker, MDRiverview, Fl

Jared Turner, MDFarmington, CT

Samir Undavia, MDNew York, NY

Jose Uribe, MDFanwood, NJ

Pao Vang, MDPhoenix, AZ

108

Hannah Vargas, MDOlathe, KS

Konstantin Vasyukevich, MDBronx, NY

T K Venkatesan, MDChicago, IL

Raul G Vila-Ramirez, MDSan Juan, Puerto Rico

Eric J Villagra, MDMexico City, MX

Daniel Viner, MDNashville, TN

Daniel Dragomir Vukas, MDChicago, IL

Bryan Wachter, MDAnchorage, AK

Curtis Walsh, MDMaywood, IL

Bryan Kent Wilcox, MDColorado Springs, CO

Mark A Williams, MD PhDNashville, TN

Gabriel Ho-Yu Wong, MDGibbsboro, NJ

William A Wood, MDPittsburgh, PA

Vivian Wu, MDPortland, OR

Dorise HC Yang, MDGulf Shores, AL

Thomas Yen, MDSan Francisco, CA

Daniel William Yoon, MDOmaha, NE

Dayton Leonard Young, MDGainesville, FL

Philip A Young, MDSanta Rosa, CA

Kathy K Yu, MDChapel Hill, NC

David Kiehyun Yun, MDGlendale, CA

Warren H Zager, MDNorristown, PA

Philip Zald, MDPortland, OR

Kelly Zander, MDAurora, CO

Jacob W Zeiders, III, MDTampa, FL

Daniel M Zeitler, MDNew York, NY

Regular MembersDavid A. Abraham, MDThief River Falls, MN

Manoj T. Abraham, MDPoughkeepsie, NY

Ravi Agarwal, MDGlendale, AZ

Robert A Akins, MDSioux Falls, SD

C. Barrett Alldredge, MDLafayette, LA

109

Vinod Anand, MDJackson, MS

Mark Andreozzi, DOWarwick, RI

Joel Anthis, MDKaty, TX

Michael Armstrong, MDRichmond, VA

James H. Atkins, MDBoerne, TX

Mitchell B. Austin, MDOrlando, FL

Robert S. Bahadori, MDFairfax, VA

Sean Bailey, MDSaint Louis, MO

Leslie L Baker, MDPowell, TN

Stephen Bansberg, MDPhoenix, AZ

Philip Bartlett, MDTiburon, CA

Mark R. Bassett, MDSpokane, WA

William Bauer, MDFernandina Beach, FL

Eric D Baum, MDMadison, CT

Mary Margaret Beauchamp, MDRome, GA

Daniel Becker, MDSewell, NJ

Marta T Becker, MDPhiladelphia, PA

Samuel S Becker, MDPrinceton, NJ

Ann Bell, MDWaverly, IA

William Belles, MD PCTonawanda, NY

Carlos Benavides, MDManchester, CT

Thomas Benda, Jr., MDDubuque, IA

Alan Berger, MDConshohocken, PA

Chris M Bergeron, MDSan Diego, CA

Leslie Berghash, MDPort Saint Lucie, FL

Gerald Berke, MDLos Angeles, CA

Daniel R. Berner, MDLafayette, IN

Joseph M Bernstein, MDWhite Plains, NY

Shelley R Berson, MDWest Nyack, NY

Michael Bertino, MDSan Antonio, TX

Nikhil Bhatt, MDElgin, IL

Neil Bhattacharyya, MDBoston, MA

110

Andrew Blank, MDScarsdale, NY

Andrew Blitzer, MDNew York, NY

Ann Bogard, MDWinston Salem, NC

Robert E. Bonham, MDDallas, TX

Joseph Houston Bosley, MDShreveport, LA

Robert Boucher, MDPhiladelphia, PA

David Bowling, MDStoneham, MA

John Boyajian, MDBoise, ID

Holly Christine Boyer, MDStillwater, MN

Cheryl Braud, MDBaton Rouge, LA

J. George Braun, MDNew York, NY

Jack Breaux, Jr., MDBaton Rouge, LA

Amy C. Brenski, MDDallas, TX

William Briggs, MDArlington, TX

Kenneth Briskin, MDChester, PA

David R Brown, MDSanta Fe, NM

Orval E. Brown, MDDallas, TX

Seth M Brown, MDWest Hartford, CT

Grady L. Bryant, Jr., MDHermitage, TN

Brad Buell, MDBismarck, ND

Nicolas Busaba, MDBoston, MA

David Caldarelli, MDChicago, IL

Michael Callahan, MDGainesville, GA

Craig Calloway, MDVisalia, CA

Joseph Campanelli, MDWoodbury, MN

Andrew Campbell, MDSheboygan, WI

Dwayne T. Capper, MDIowa City, IA

Henry M Carder, MDDallas, TX

Daniel G. Carothers, MDChicago, IL

Ricardo Carrau, MDPittsburgh, PA

Octavio D Carreno, MDEllsworth, Maine

Russell P Cecola, MDNew Orleans, LA

111

Antonio Cedin, MDSao Paulo, Brazil

Fayez Chahfe, MDUtica, NY

Socorro A. Chamblee, MDMcKinney, TX

Gretchen Champion, MDAllen, TX

CW David Chang, MDColumbia, MO

Dennis F Chang, MDLoma Linda, CA

Bradley J. Chastant, MDLafayette, LA

Rashid Chaudhry, MDBrooklyn, NY

Alexander Chester, MDWashington, DC

Dewey Christmas, Jr., MDOrmond Beach, FL

Clifford Timothy Chu, MDBrick, NJ

William Cobb, MDFrisco, TX

Joel Cohen, MDScottsdale, AZ

Noam Cohen, MDPhiladelphia, PA

Daryl G Colden, MDNorth Andover, MA

William Collins, MDGainsville, FL

J. Robert Coltharp, Jr., MDHattiesburg, MS

Jeff Comer, MDFort Myers, FL

David J Congdon, MDWaterloo, IA

Laurence V. Cramer, DOPhoenixville, PA

Richard T. Crane, MDEau Claire, WI

Michael Crawford, MD Omaha, NE

Jeffrey Cutler, MDGaithersburg, MD

Agnes Czibulka, MDGuilford, CT

Kamal Daghistani, MDSaudi Arabia,

Lawrence Danna, MDWest Monroe, LA

Ronald Darling, MDWrukesha, WI

Subinoy Das, MDColumbus, OH

Terence Davidson, MDSan Diego, CA

William Davidson, MDJesup, GA

Douglas Dawson, MDMuscatine, IA

Richard J De Persio, MDKnoxville, TN

112

James Denninghoff, MDColumbia, MO

Martin Desrosiers, MDCanada,

Thomas deTar, MDPost Falls, ID

Michael DeVito, MDAlbany, NY

Laurence DiNardo, MDRichmond, VA

Linda Dindzans, MDMequon, WI

David Dinges, MDDalton, GA

Hamilton Dixon, MDRome, GA

Thomas Dobleman, MDOmaha, NE

George Domb, MDRedding, CA

Paul Donald, MDSacramento, CA

James Donegan, MDLebanon, NH

Glenn Drumheller, DOEverett, WA

Larry Duberstein, MDMemphis, TN

Wallace Duff, MDOmaha, NE

Thane Duncan, MD, PhD.Cordova, TN

James Duncavage, MDNashville, TN

Bernard Durante, MDPlymouth, MA

Dory Durr, MDOutremont, Quebec, Canada

Andrew Dzul, MDSt Clair Shrs, MI

Charles S. Ebert, MD, MPHChapel Hill, NC

John F Eisenbeis, MDSaint Louis, MO

Lee Eisenberg, MDEnglewood, NJ

Jean Anderson Eloy, MDNewark, NJ

Moshe Ephrat, MDNew Hyde Park, NY

Joel Ernster, MDColorado Springs, CO

Karin Evan, MDMinneapolis, MN

Kenneth H. Farrell, MDFort Lauderdale, FL

Russell Faust, MD, PhDColumbus, OH

Kenneth Faw, MDKirkland, WA

Barry Feinberg, MDEncino, CA

Bruce Feldman, MDChevy Chase, MD

113

Robert Fieldman, MDWest Orange, NJ

Samuel Fisher, MDDurham, NC

Robert A. Fishman, MDSt Clair Shrs, MI

Ray Fontenot, Jr., MDBeaumont, TX

Rick A. Fornelli, MDFairview, PA

Stephen Freifeld, MDSpringfield, NJ

Michael Friedman, MDChicago, IL

Robert Gadlage, MDDuluth, GA

Ryan Gallivan, MDBend, OR

Christopher Garvey, MDJacksonville, FL

Clarence Gehris, MDLutherville, MD

Mark E. Gerber, MDEvanston, Il

Roland Gerencer, MDAlbuquerque, NM

John Gerwin, MDBirmingham, AL

Anne Getz, MDSt. Louis, MO

Mahmoud M Ghaderi, MDSpringfield, PA

Randal B Gibb, MDPayson, UT

Christina M Gillespie, MDEl Paso, TX

David Gitler, MDBronx, NY

Paul Gittelman, MDMamroneck, NY

Bradley E. Goff, MDCartersville, GA

Scott Gold, MDNew York, NY

Andrew Golde, MDAtlanta, GA

Steven Goldman, MDBeachwood, OH

Bradley J Goldstein, MDEllsworth, ME

Harsha Gopal, MDChestnut Hill, MA

Benoit Gosselin, MDLebanon, NH

Satish Govindaraj, MDNew York, NY

Parul Goyal, MDSyracuse, NY

Jon W. Graham, MDWinfield, AL

Iain Grant, MDColumbus, OH

John Griffin, MDMacon, GA

114

Murray Grossan, MDLos Angeles, CA

Barbara Guillette, MDWarwick, RI

Anil A Gungor, MDTemple, TX

Ray O. Gustafson, MDRochester, MN

Avraham Hampel, MDElkins Park, PA

Steven Handler, MD, MBEPhiladelphia, PA

Scott Hardeman, MDSt. Louis, MO

William Harmand, MDSyracuse, NY

Philip A. Harris, MDWichita, KS

James M Harrison, MDMobile, AL

Scott Edwin Harrison, MDJackson, MS

Joseph E Hart, MDWaterloo, IA

Makoto Hasegawa, MDJapan,

Richard Haydon, III, MDLexington, KY

H. Graves Hearnsberger, III, MDLittle Rock, AR

Richard L. Hebert, II, MDEunice, LA

Timothy J Heffron, MDRaleigh, NC

Arthur Hengerer, MDRochester, NY

David Henick, MDFort Lee, NJ

James H Heroy, III, MDLas Vegas, NV

Peter Hillsamer, MDLafayette, IN

Daniel Hinckley, MDIdaho Falls, ID

Brad Hinrichs, MDPalo Alto, CA

Hunter Hoover, MDCharlotte, NC

Steven Horwitz, MDSkokie, IL

John Houck, MDOklahoma City, OK

Mark Howell, MDJohnson City, TN

Abraham Hsieh, MDWalnut Creek, CA

Darrell Hunsaker, MDSan Diego, CA

Michael K. Hurst, MDMorgantown, WV

William David Isenhower, MDGreenwood, SC

Alexis Jackman, MDBronx, NY

115

Keith A Jackson, MDSan Diego, CA

Ian N. Jacobs, MDPhiladelphia, PA

Basem M Jassin, M.D.Ennis, TX

John A. Jebeles, MDBirmingham, AL

John Jiu, MDJonesboro, AR

Jacob Johnson, MDSan Francisco, CA

Jonas Johnson, MDPittsburgh, PA

Jerry Josen, MDScottdale, AZ

Jordan Josephson, MDNew York, NY

Charles Juarbe, MDBayamon, PR

Ashutosh Kacker, MDNew York, NY

Zoheir J. Kaiser, MDSouth Hill, VA

James Kallman, MDAnchorage, AK

Seth Kanowitz, MDMorristown, NJ

Shalini Kansal, MDBuffalo, NY

Paul Kaplan, MDPortland, OR

Edward Kass, MDWaukesha, WI

Matthew Kates, MDNew Rochelle, NY

Savvas Kazanas, MDAthens, Greece

John Keebler, MDMobile, AL

Michael Kelleher, MDSalisbury, MD

Robert M. Kellman, MDSyracuse, NY

Marc Kerner, MDNorthridge, CA

David Keschner, MDMission Viejo, CA

Umang Khetarpal, MDBrownsville, TX

Shaun Kilty, MDOttawa, Ontario, CAN

Daniel Kim, MDWorcester, MA

Jean Kim, MDBaltimore, MD

Charles Kimmelman, MDNew York, NY

Joost L Knops, MDBellingham, WA

Christopher Knox, D.O.Dover, NH

Charles Koopmann, Jr., MDAnn Arbor, MI

116

Jodi M. Kornak, MDMilwaukee, WI

Yosef Krespi, MDNew York, NY

Lane Krevitt, MDNew York, NY

Siobhan Kuhar, M.D.Albany, NY

Gary P Landrigan, MDBurlington, VT

Christopher Gene Larsen, MDKansas City, KS

Arthur M. Lauretano, MDChelmsford, MA

Francois Lavigne, MDMont Royal, QC, Canada

William Lawson, MD, DDSNew York, NY

Amy D. Lazar, MDSomerville, NJ

Robert Lebovics, MDNew York, NY

Richard Lebowitz, MDNew York, NY

Phillip Lee, MDMason City, IA

Brett A Levine, MDTorrance, CA

Meron Levitats, MDLighthouse Point, FL

Roy S Lewis, MDHouston, TX

Jessica Lim, MDNew York, NY

Sandra Lin, MDBaltimore, MD

John A Lindgren, MDPortland, OR

Robert G. Lisk, MDGlen Birnie, MD

Philip Liu, MDHonesdale, PA

Drew Locandro, MDMarietta, GA

Todd A. Loehrl, MDMilwaukee, WI

Lloyd Loft, MDNew York, NY

Christopher M. Long, MDGreenfield, WI

Paul C Ludlow, MDReno, NV

Valerie Lund, MDUnited Kingdom,

Rodney p Lusk, MDOmaha, NE

Mendy S Maccabee, MDHood River, OR

Kenneth Mak, MDModesto, CA

Kiyoshi Makiyama, MD, PhDJapan

Bruce T. Malenbaum, MDDurham, NC

117

Aditi Mandpe, MDSan Francisco, CA

Jeffrey Manlove, MDSt. Paul, MN

Scott Manning, MDSeattle, WA

Richard A Martin, MDCape Girardeau, MO

Dean Martinelli, MDOconomowoc, WI

Marc D Maslov, MDSeneca, PA

Brian L. Matthews, MDWinston-Salem, NC

Stuart A McCarthy, MDUpland, CA

Scott McCary, MDHuntsville, AL

Percy McDonald, MDPort Huron, MI

Robert McDonald, Jr., MDJefferson City, MO

Johnathan D. McGinn, MDHershey, PA

John T. McMahan, MDChicago, IL

Mark Mehle, MDLakewood, OH

Arlen Meyers, MDAurora, CO

Shabir Mia, MDSaskatoon, Saskatchew

Harry C Midgley, III, MDJupiter, FL

Suzette K. Mikula, MDWashington, DC

Presley M Mock, MDDallas, TX

Denise C. Monte, MDE. Setauket, NY

Marcus Moody, MDLittle Rock, AR

J. Spencer Mooney, MDBrookhaven, MS

William Moran, MDWeston, WI

Alice Morgan, MDCullman, AL

Charles Morgan, MDBirmingham, AL

Todd Morrow, MDWest Orange, NJ

Ron L. Moses, MDHouston, TX

Ali Moshaver, MDPenticton, BC,

Sam Most, MDStanford, CA

Brooks Mullen, MDSequin, TX

Harlan Muntz, MDSalt Lake City, UT

Michael P Murphy, MDMinneapolis, MN

118

Andrew Murr, MDSan Fransisco, CA

John Murray, MDWest Palm Beach, FL

Robert Naclerio, MDChicago, IL

Ravi Nadarajah, MDUniontown, PA

Matthew Nagorsky, MDPhiladelphia, PA

David Nash, MDStoneham, MA

Shawn Nasseri, MDBeverly Hills, CA

Michael Neuenschwander, MDHendersonville, NC

Brad Nitzberg, MDBoca Raton, FL

Michael Nordstrom, MDGreenfield, WI

Frederick Nunnally, MDDothan, AL

Erin K. O'Brien, MDIowa City, IA

Robert Oberhand, MDWestfield, NJ

Samuel Mark Overholt, MDKnoxville, TN

Ralph Glen Owen, Jr., MDAugusta, GA

Ariadna Papageorge, MDNew York, NY

Sanjay Parikh, MDBronx, NY

Albert Park, MDSalt Lake City, UT

Michael J Parker, MDCamillus, NY

Nigel Pashley, MB, BSDenver, CO

Joseph Paydarfar, MDLebanon, NH

Spencer C Payne, MDCharlotteville, VA

Aaron Pearlman, MDNew York, NY

Andrew Pedersen, MDPortland, OR

Steven Peskind, MDPlano, TX

Jay Piccirillo, MDSaint Louis, MO

Timothy Pingree, MDLone Tree, CO

Michael Platt, MDBoston, MA

Steven Pletcher, MDSan Francisco, CA

David M Poetker, MDMilwaukee, WI

Alan Pokorny, MDSpokane, WA

Juan Portela, MDDorado, PR

119

William Potsic, MDPhiladelphia, PA

Kevin Potts, MDProspect, KY

W. Bruce Povah, MDCanada,

J. Christopher Pruitt, MDColorado Springs, CO

Magda R. Pugh, MDRaleigh, NC

Christine Puig, MDAuburn, WA

Melissa Pynnonen, MDAnn Arbor, MI

Chris Quilligan, MDFullerton, CA

Joseph Ron Raviv, MDEvanston, IL

Eileen M Raynor, MDJacksonville, FL

Edward Reardon, MDMilton, MA

Elie Rebeiz, MDBoston, MA

Douglas David Reh, MDBaltimore, MD

Ryan M. Rehl, MDPhoenix, AZ

Patrick Matthew Reidy, MDFort Myers, FL

Bruce Reisman, MDOceanside, CA

Evan Reiter, MDRichmond, VA

Michael Rho, MDStoneham, MA

William Richtsmeier, MD, PhdCooperstown, NY

Ricardo A. Roa, MDProctorville, OH

Jeffrey Roach, MDCambridge, MA

Donald Rochen, DOWest Bloomfield, MI

Shawn E. Rogers, MDEdmonds, WA

Anthony Rogerson, MDMonroe, WI

Marc R Rosen, MDPhiladelphia, PA

Louis Rosner, MDRockville Center, NY

Douglas Ross, MDBridgeport, CT

Apostolos Rossos, MDHamilton, NJ

Brian Rotenberg, MDLondon, Ontario, Canada

David Rudman, MDOverland Park, KS

Mauro B Ruffy, Jr., MDSan Jose, CA

Jose Ruiz, MDMiami, FL

120

C. Allan Ruleman, Jr., MDMemphis, TN

Paul T Russell, III, MDNashville, TN

Scott Saffold, MDBelle Haven, VA

Hamed Sajjadi, MDSan Jose, CA

Mark Samaha, MDMontreal, Canada

Anthony Sanders, MDColumbus, IN

J. R. Sarpa, MDBloomington, IN

Michael Saylor, MDHagerstown, MD

Stanley Schack, MDOmaha, NE

Scott Schaffer, MDGibbsboro, NJ

Barry Schaitkin, MDPittsburgh, PA

Troy D Scheidt, MDColumbia, MO

Timothy J. Schneider, MDEaston, MD

Todd Schneiderman, MDBridgewater, NJ

James Wilber Schroeder Jr., MDChicago, IL

Michael L Schwartz, MDWest Palm Beach, FL

Michael Seicshnaydre, MDGulfport, MS

Ilana Seligman, MDWinnetka, IL

Peter Selz, MDDenison, TX

Russell Semm, MDLincoln, NE

Christopher Shaari, MDHackensack, NJ

Howard Shaffer, MDFort Worth, TX

Frank Shagets, Jr., MDJoplin, MO

Ashish Shah, MDColumbus, OH

Nina Shapiro, MDLos Angeles, CA

Daniel Sharkey, MDStuart, FL

Michael Shohet, MDNew York, NY

Joseph Siefker, MDFort Walton Beach, FL

Ashley Sikand, MDLas Vegas, NV

Andrew Silva, MDSterling, VA

Steven Silver, MDAlbany, NY

John Simmons, MDJasper, AL

121

George Simpson, MDBuffalo, NY

John Simpson, MDAthens, GA

Thomas A Simpson, MDIowa City, IA

Abraham Sinnreich, MDStaten Island, NY

David Slavit, MDNew York, NY

Bruce M. Smith, MDFort Collins, CO

Steven R Smith, MDHuntsville, AL

Gary Snyder, MDBayside, NY

Carl Snyderman, MDPittsburgh, PA

Raymond Soletic, MDManhasset, NY

Michael S Srodes, MDPittsburgh, PA

Sarah Stackpole, MDNew York, NY

Gary Stadtmauer, MDNew York, NY

Kirk Steehler, DOErie, PA

Vernon H. Stensland, MDSioux Falls, SD

Carl W Stevens, II, MDEllisville, MS

Gerald Stinziano, MDBuffalo, NY

Victor Strelzow, MDIrvine, CA

Mark Stroble, MDKirkwood, MO

Edward Bradley Strong, MDSacramento, CA

Joseph Sugerman, MDBeverly Hills, CA

Abtin Tabaee, mdNew York, NY

Mark H Tabor, MDTampa, FL

Masayoshi Takashima, MDHouston, TX

Robert F. Tarpy, MDLafayette, LA

Barry Tatar, MDEllicott City, MD

Jeffrey Terrell, MDAnn Arbor, MI

Stanley Thawley, MDSaint Louis, MO

Roy Thomas, MDMountain View, CA

Hilary Timmis, Jr., MDBellvue, OH

Lawrence Tom, MDPhiladelphia, PA

William Trimmer, MDReno, NV

122

Theodore Truitt, MDSt. Cloud MN, MN

Ewen Tseng, MDFrisco, TX

Feodor Ung, MDLombard, IL

Peter Vandermeer, MDHolland, MI

Adrian Varela, MDMilwaukie, OR

Bowen Vaughan, MDHastings, NE

Giri Venkatraman, MDLebanon, NH

Shridhar Ventrapragada, MDBurlington, MA

Michael J. Vietti, MDMansfield, OH

Thomas Viner, MDIowa City, IA

Eugenia Vining, MDNew Haven, CT

David Volpi, MDNew York, NY

David L. Walner, MDNiles, IL

Manish Wani, MDKaty, TX

Mark Wax, MDPortland, OR

Edward Weaver, MD, MPHSeattle, WA

Debra Weinberger, MDDallas, TX

Raymond L Weiss, MDOcean Springs, MS

Kevin C Welch, MDMaywood, IL

Samuel Welch, MD, PHDLittle Rock, AR

Barry Wenig, MDEvanston, IL

Jeffrey Werger, MDMarkham Ontario, Canada

Richard W Westreich, MDBrooklyn, NY

Ralph F Wetmore, MDPhiladelphia, PA

Ronald Whitmire, MDGainesville, GA

William J. Wiggs, MDFayetteville, NC

Robert Williams, MDBuffalo, NY

Mark Wilson, MDGrand Haven, MI

Bradford Winegar, MDAustin, TX

Birgit Winther, MDCharlottesville, VA

Sarah K Wise, MDAtlanta, GA

Troy D. Woodard, MDSolon, OH

123

B Tucker Woodson, MDMilwaukee, WI

Bradford Alan Woodworth, MDBirmingham, AL

Geoffrey Wright, MDAmarillo, TX

Bozena B Wrobel, MDLos Angeles, CA

James Wu, MDDaly City, CA

J Robert Wyatt, MDGarland, TX

Allison N Wyll, MDGarland, TX

Ken Yanagisawa, MDNew Haven, CT

Kathleen Yaremchuk, MDDearborn, MI

James Yeh, MDWest Covina, CA

Mathew Yetter, MDWinston-Salem, NC

John K. Yoo, MDHouston, TX

Ramzi T Younis, MDCoral Gables, FL

Mani H. Zadeh, MDLos Angeles, CA

Jill F. Zeitlin, MDBriarcliff Manor, NY

Warren H. Zelman, MDGarden City, NY

Lee Zimmer, MD,PHDCincinnati, OH

Fellow MembersRobert F. Aarstad, MDShreveport, LA

Ford Albritton IV, MDDallas, TX

Kenneth Altman, MDNew York, NY

Ronald Amedee, MDNew Orleans, LA

Benjamin Asher, MDNew York, NY

Gerald Bart, MDHillsboro, OH

Evan Bates, MDDallas, TX

Timothy R. Boyle, MDMarshfield, WI

Paul Brindley, MDHouston, TX

Steven Buck, MDBuffalo, NY

Peter Joseph Catalano, MDBurlington, MA

James Chow, MDWinfield, IL

Lanny Close, MDNew York, NY

Jan S. Connelly, MDSpokane, WA

124

Kim L. Dakin, MDOpelousas, LA

Norman Druck, MDChesterfield, MO

Berrylin Ferguson, MDPittsburgh, PA

Marvin P. Fried, MDBronx, NY

Andrew R. Ganz, MDNew York, NY

M. Alan Goodson, MDBirmingham, AL

James D. Gould, MDTown & Country, MO

Scott Graham, MDIowa City, IA

James A Hadley, MDRochester, NY

Gady Har-El, MDHollis, NY

Edward J Hepworth, MDDenver, CO

William Holmes, MDFairmont, MN

Norman Holzberg, MDWest Orange, NJ

Larry Hoover, MDKansas City, KS

Scott Huebsch, MDCedar Rapids, IA

Charles Hurbis, MDCoos Bay, OR

Joseph Jacobs, MDNew York, NY

Stephanie Joe, MDChicago, IL

John Kalafsky, MDNorfolk, VA

Lawrence Kaufman, MDAlbany, NY

David Kennedy, MDPhiladelphia, PA

Jeffrey Krivit, MDCedar Rapids, IA

Frederick Kuhn, MDSavannah, GA

Donald C. Lanza, MDSt. Petersburg, FL

Jern-Lin Leong, mdSingapore

Donald Leopold, MDOmaha, NE

Steven C Marks, MDHavre de Grace, MD

Bradley F Marple, MDDallas, TX

F. Anthony McLeod, MDAlexander City, AL

Kevin McMains, MDSan Antonio, TX

H. Christopher Moore, MDFullerton, CA

John Richard Morris, Jr., MDLouisville, KY

125

Erik G Nelson, MDGurnee, IL

J. David Osguthorpe, MDCharleston, SC

John Pallanch, MDRochester, MN

Thomas Pasic, MDMadison, WI

James Pitcock, MDMobile, AL

Jeffrey Powell, MD, DDSChesapeake, VA

Edmund A Pribitkin, MDPhiladelphia, PA

B Manrin Rains, MDMemphis, TN

Dale Rice, MDLos Angeles, CA

Arthur Rosner, MDSterling Hts., MI

Steven Schaefer, MDNew York, NY

Rodney J. Schlosser, MDCharleston, SC

Jerry Schreibstein, MDSpringfield, MA

Brent A Senior, MDChapel Hill, NC

Anthony Sertich, MDSan Antonio, TX

Gavin Setzen, MDAlbany, NY

Michael Setzen, MDGreat Neck, NY

Raj Sindwani, MD, FRCSSt. Louis, MO

Joe Frank Smith, MDDothan, AL

James Stankiewicz, MDMaywood, IL

Bruce Sterman, MDAkron, OH

Michael Stewart, MDNew York, NY

Scott P. Stringer, MD, MSJackson, MS

Fred J. Stucker, MDShreveport, LA

Krishnamurthi Sundaram, MD Brooklyn, NY

Ron Swain, Sr., MDMobile, AL

Evan Tobin, MDNew Albany, OH

Paul Toffel, MDGlendale, CA

Ralph Tyner, MDDavenport, IA

Richard Waguespack, MDBirmingham, Al

Gregory Wolf, MDAnn Arbor, MI

126

InternationalMembersSameer Ali BafaqeehRiyadh, Saudi Arabia

Chiara Bellini, MDItaly

Manuel Bernal-Sprekelsen, MDBarcelona

Estelita G.T. Betti, M.D.Sao Paulo, Brazil

Christopher Brown, MDElwood, Australia

Richard Douglas, MDAuckland, New Zealand

Ron Eliashar, M.D.Jerusalem, Israel

Firas Farhat, MDBeirut, Lebanon

Robinson Granados, MDMiami, FL

Alfredo Herrera, MDColumbia

Rafael Hijano-Esque, MDBarcelona, Spain

Jeremy Hornibrook, MDNew Zealand

Larry Kalish, MDEdgecliff NSW

Toru Kikawada, MDHamamatsu, Shizuoka, Japan

Steve P. Kloppers, MDChilliwack, BC, Canada

Jean Michel Klossek, MDFrance

Kazuhiro Nakaya, MD

Piero Nicolai, MDBrescia, Italy

Edgard Novelo-Guerra, MDMexico

Pietro Palma, MDItaly

Simon R Robinson, MDWellington, New Zealand

Adrian Saurajen, MDSingapore, Singapore

Chih-Hung Shu, MDTaipei, Taiwan 112

Hamidreza Sohrabi, MDIsfahan, Iran

Vanda Stepanek, MD, PhDHouston, TX

Pongsakorn Tantilipikorn, MDBangkok, Thailand

Matteo Trimarchi, MDMilano, Italy

Alvaro G. Valenzuela, MDChile

Richard L. Voegels, MDSao Paulo, Brazil

Hans-J Welkoborsky, MDDDS, PhDGermany

127

Peter-John Wormald, MDAdelaide, Australia, SA

Carlos Yanez, MDMexico

Life MembersPierre G. Arbour, MD Boynton Beach, FL

Edward Brandow, Jr., MD Albany, NY

Herbert Camp, MD Midland, MI

John Campbell, MD Tulsa, OK

Richard Carter, MD Greenwood, SC

James Dudley, MD San Fransisco, CA

Gerald English, MD Englewood, CO

George Facer, MD Rochester, MN

William Friedman, MD Saint Louis, MO

Ralph Gaskins, MD Atlanta, GA

Seth Goldberg, MD Potomac, MDHarold Groves , DO Eugene, OR

Moshe Harell, MDIsrael

Sanford Hoffman, MDBuffalo, NY

Ahamefule Olu Ibekwe, MD Saudi Arabia

Frank L. Kardos, MD Wayne, NJ

Jeffrey Kerner, MD Trumbull, CT

Assad Khoury, MD Washington, NY

Robert Komorn, MD Houston, TX

Helen Krause, MD Gibsonia, PA

William Lavelle, MD Worcester, MA

Richard Mabry, MD Frisco, TX

William Mancoll, MD Hartford, CT

Kenneth Mattucci, MD Manhasset, NY

Pradip Mistry, MD Norfolk, NE

Y. M. Naci, MD Startford, CT

Supote Phipatanakul, MD Valley Park, MO

Conrad A. Proctor, MD Royal Oak, MI

Vittal Rao, MD LaGrangeville, NY

128

Edward Razim, MD Oak Brook, IL

C. Robinson, MDAlbuquerque NM

John Sellers, MD Norfolk, VA

Carl Sputh, MDIndianapolis, IN

William Stone, MD Hopkinton, NH

Robert Toohill, MD Milwaukee, WI

Richard Weir, MD Spartanburg, SC

Eiji Yanagisawa, MD New Haven, CT

Anthony Yonkers, MD Omaha, NE

Richard Yules, MD Boca Raton, FL

Life MembersPat A Barelli, MDOverland Park, KS

Stanley M. Blaugrund, MDNew York, NY

Charles Clark, III, MDDurham, NC

Larry H. Day, MDMoselle, MS

David Fairbanks, MDBethesda, MD

Tierry Garcia, MDIndianapolis, IN

Howard Gelman, MDAnnapolis, MD

Charles W. Gross, MDCharlottesville, VA

Eugene Hesdorffer, MDJackson, MS

Charles Kaluza, DOPortland, OR

Herbert Kean, MDPhiladelphia, PA

Chandra Khasgiwala, MDAndover, MA

Anthony Maniglia, MDCleveland, OH

Jean Marti, MDSwitzerland,

Robert McGrew, MDLittle Rock, AR

Winsor Morrison, MDHollister, MO

John Odess, MDChelsea, AL

Loring W. Pratt, MDFairfield, ME

Michael Riley, DOLargo, FL

Alan Sogg, MDRussell, OH

Edward Starinchak, MDGranville, OH

129

M. Eugene Tardy, MDChicago, IL

Charles Wine, MDOklahoma City, OK

HonoraryMemberThomas McDonald, MDRochester, MN

COSM 2010 56th Annual MeetingApril 28-May 2, 2010 September 25, 2010Bally’s, Las Vegas, NV Boston, MAAbstract Submission Abstract Submission Deadline: 10/31/2009 Deadline: 5/21/2010

Manuscript Submission Manuscript Submission Deadline: 4/1/2010 Deadline: 8/28/2010

COSM 2011 57th Annual MeetingApril 28-May 1, 2011 September 10, 2011Sheraton Chicago San Francisco, CAHotel & TowersChicago, IL

COSM 2012 58th Annual MeetingApril 18-22, 2012 (Location: TBD)Manchester Grand HyattSan Diego, CA

COSM 2013 59th Annual MeetingApril 10-14, 2013 (Location: TBD)JW Marriott Grande LakesOrlando, FL

Save the Date

Questions?Contact Wendi Perez, Administrator

Tel: 845.988.1631 • Fax: 845.986.1527Email: [email protected]

www.american-rhinologic.org

55 annual meeting - american rhinologic · inadequate health insurance cost cov-erage a major...

Documents