Chronic Sinusitis and The Best Possible Treatment

Banno; Page | 23

wayne state university school of medicine

Chronic Sinusitis and The Best Possible Treatment

BMS 7999

Fady Banno

12/202013

Table of ContentsTables and Diagrams ------------------------------------------------ page 1

Introduction ----------------------------------------------------------- page 2

Background ----------------------------------------------------------- page 3

Method ---------------------------------------------------------------- page 3

Body ------------------------------------------------------------------- page 5-15

Discussion ------------------------------------------------------------ page 16-18

Conclusion ------------------------------------------------------------ page 19-20

References ------------------------------------------------------------ page 21-22

Biographical sketch ------------------------------------------------- page 23Tables and Diagrams:Diagram 1 page 5

Diagram 2 page 14

Diagram 3 page 15

Table 1 page 12

Chronic Sinusitis and the Best Possible Treatment

Introduction:

Sinusitis also called rhinosinusitis, is defined by the inflammation of the paranasal sinuses caused by an infection, allergy or even autoimmune conditions. The paranasal sinuses are air filled structures that are found in our bony facial skeleton. There are four paranasal sinuses that are adjacent to the nasal cavity that could be inflamed and result in symptoms such as nasal obstruction, thickened nasal drainage, and facial pain or pressure. When the mucosa of the sinus and nasal cavities get inflamed and swell, it will lead to the obstruction of the sinuses. This will cause poor circulation of air and blockage of the secretions produced. Therefore, the environment in the sinuses would be ideal for bacterial infection, and the swelling would lead to the buildup of facial pressure and pain. Since sinusitis affects about 30 million people in the United States, the healthcare cost is estimated to be $5.8 billion from ambulatory and emergency department services every year. Many antibiotics are being prescribed after diagnosing the disease, making it the fifth most common disease for which an antibiotic is prescribed (Rosenfeld, 2007). There is acute sinusitis, which is characterized as an infection that last two to four weeks, and chronic sinusitis associated with persistent inflammation of the mucosa of the nose and paranasal sinuses for longer than three or four months.

Chronic sinusitis, also called chronic rhinosinusitis (CRS), has significant socioeconomic implications. Patients with CRS have a significant negative impact on their health which affects their social interactions, physical activities, work, and also mood. Patients with CRS suffer from worse bodily pain and social functioning than do those with angina, back pain, congestive heart failure, and chronic obstructive pulmonary disease (Rosenfeld, 2007). Understanding the pathophysiology of CRS will lead to better therapeutic decisions with the potential for an effective treatment and better patient outcomes.

Background:

Chronic rhinosinusitis (CRS) is a complex disease with several variants of different pathophysiologies. There are many different CRS phenotypes described. These phenotypes are defined by recognizable characteristics such as different anatomical features in the opening of the sinuses or the presence or absence of nasal polyps. The limited knowledge of the pathophysiology of these variants limits our understanding to the causes of CRS and our ability to improve the treatment options available. Even if the clinical phenotypes are identified, this doesnt indicate the underlying pathophysiologic mechanisms of CRS. The diversity of CRS phenotypes due to distinct pathophysiologic mechanism created endotypes for CRS (Meltzer, 2004). These endotypes can be classified based on how well each endotype of CRS responds to treatment such as antibiotics or corticosteroids. In the past, CRS has been treated as a single disease. Failure to identify these phenotypes prevents the ability to define an effective treatment for each CRS patient (Meltzer, 2004).

Methods:

This paper will review the pathophysiology of chronic rhinosinusitis (CRS). This will allow a better understanding of the disease and provide the ability to propose better treatment. This review is to describe the different proposed pathophysiologic mechanisms of CRS as well as diagnostic and treatment strategies for the management of this complex disease. Body:All forms of chronic rhinosinusitis are associated with the loss of a protective barrier or unstable innate immune functions that the body relies on to prevent infection of the sinuses in a healthy person. This leads to loss of sterility of the sinuses because they are more susceptible to infections by anaerobic and gram-positive bacteria, such as Staphylococcus aureus. Usually, if the patients health is not improved at twelve weeks of antibacterial therapy, then the patient should be evaluated for other factors, such as the presence of anatomical abnormalities or allergies (Meltzer, 2004).

Diagram 1: Paranasal Sinuses

Each person has a unique structure of paranasal sinuses, the anatomical features may vary markedly. Therefore, understanding the anatomy and the physiology of the paranasal sinuses is helpful to determine a treatment for each patient. By understanding the anatomy of the sinuses, different screening techniques could be used to examine the different sinuses, such as nasal endoscopy (a thin and flexible endoscope with fiber-optic light that can be inserted easily in the patients nose and hence visualize and inspect the nasal sinuses), computerized tomography (CT) scan and magnetic resonance imaging (MRI). These modalities can give a great detailed visualization of the nasal sinuses that might help detect any physical obstruction and inflammation around the area of the nasal sinuses (harder to see using an endoscope).

Patients with chronic rhinosinusitis are identified pathologically by increased bacterial colony counts from 103 to 106 units/mL in the sinuses which reflects the loss of some defensive mechanisms responsible for maintaining sinus sterility in a healthy person (Hoover, 1997).

The role of microorganisms in patients with chronic rhinosinusitis (CRS) is not clear. This is not the case in the acute sinusitis, which is triggered by infectious organisms most of the time. There are many different hypotheses about what microorganisms cause CRS which leads to an inappropriate use of antibiotics. Studying the sinus cavities and the types of bacteria found there yielded variable results in patients with CRS. For example, Streptococcus species and Staphylococcus aureus were common, as well as Haemophilus, Pseudomonas, and Moraxella. Since the varieties of bacterial infection in CRS are broad, CRS may be unresponsive to antibiotics which may not be effective against the specific bacteria (Meltzer, 2004). This infection results in inflammation and accumulation of activated eosinopohils in the sinus mucosa. Eosinophils are considered to play a major role in the pathogensis of CRS via the release of toxic proteins such as eosinophil cationicprotein (Hoover, 1997). Once the diagnosis of chronic rhinosinusitis is confirmed, many patients will be prescribed antibiotics that do not work effectively even after taking them for months. This is due to the fact that bacteria may not be the major cause of CRS; more factors contribute to the severity of the disease which makes antibiotics inadequate to treat the disease some of the time. Different bacteria strains resist the antibiotic by producing biofilms which protects the extracellular matrix from antimicrobial agents. In this case, these biofilms need to be destabilized or prevented for the antibiotics to be used effectively. Further studies are required to determine the exact role of biofilms in the pathogenesis of CRS. Suggestions of a viral cause of CRS have been insufficient because of the lack of convincing evidence.

In a double-blind study, 251 CRS patients were randomized to receive ciprofloxacin or amoxicillin/clavulanic acid (Legend, 1994). It was observed that the cure rates were 51% and 50% for amoxicillin/clavulanate and ciprofloxacin, respectively. The clinical cure and bacteria eradication rates were similar between the two groups; however, at 40 days after the treatments, cure rates were higher and side effect rates were lower in ciprofloxacin groups. In another study, Namyslowski et al. (2004) evaluated the efficacy of amoxicillin/clavulanic acid and cefuroxime for 14 days in the treatment of CRS. It was observed that the cure rates were 95% and 88% for amoxicillin/clavulanate and cefuroxime, respectively. Similar rates of bacterial eradication were identified, but those treated with cefuroxime had a significantly higher rate of disease relapse.

In addition, a number of long-term studies, such as three months of therapy or more, showed that treating patients with low dose of macrolides (roxithromycin or azithromycin) is effective in improving the symptoms of CRS. Macrolide therapy represents an area of interest because of its unique anti-inflammatory properties. (De Sutter, 2006). However, the mechanism for this effect is not well understood and speculations that macrolide therapy inhibit the host immune response and weaken the virulence of bacteria are unproven (Legent, 1994).

Wallwork et al. (2006) randomized 64 patients to receive the macrolide antibiotic roxithromycin or placebo for three months (Wallwork, 2006). Roxithromycin patients had significant improvements to their symptom and nasal endoscopy tests. In another study, Videleret al. (2011) randomized 60 patients to receive azithromycin or placebo for three months (Videler, 2011). In contrast to Wallworket al. (2006), no significant subjective or objective improvements were noted in the azithromycin group, but there were more responders in the treatment group. The two studies had different dosing schedules (daily in the Wallwork study versus once daily for three days, followed by one dose weekly in the Videler study). Also, the patients in the Wallwork study did not have nasal polyps which the Videler study included. This could be the reason why the results were different between these studies. Future large placebo-controlled studies are warranted to clarify the role of macrolides in treating CRS patients. After treating the patient with multiple courses of antibiotics for a long period of time without any significant success in reducing the symptoms of chronic sinusitis, then the next line of treatment would be systemic corticosteroid therapy. It is usually considered for severe cases of CRS and CRS with nasal polyps (NPs). Since corticosteroids are potent anti-inflammatory agents that are also effective in almost all inflammatory conditions, they are accepted as a treatment for CRS. Corticosteroids help reduce the polyp size and also reduce swelling of the mucous membrane. In addition, corticosteroids inhibit inflammatory mediators which lead to a decrease in inflammation due to decreased vessel permeability and cell influx (Snow, 2009). Corticosteroid therapy should be administered carefully because of the myriad dangerous side effects, such as hypothalamic-pituitary-adrenal axis suppression, gastric ulcers, psychiatric changes, and exacerbation of diabetes, as well as chronic side effects such as weight gain, and hypertension (Snow, 2009). Although there is concern that despite the absence of strong supporting evidence that long-term treatment with corticosteroids may cause minor structural changes or even thinning of the epithelium, they are still very important modality in managing CRS and should be offered to all patients with CRS because of inhibition to inflammatory mediators (Desrosiers, 2011). Another solution to relieve symptoms of CRS is buffered nasal saline irrigation (NSI). NSI promotes healing and provide comfort for CRS patients. Harvery et al. (2007), performed multiple systematic reviews (SRs) of high-quality randomized controlled trials to evaluate the effectiveness and safety of NSI in the management of CRS. Three studies compared topical saline against no treatment, one against placebo, and one against an intranasal steroid spray. It was observed that using saline is beneficial in the treatment of chronic sinusitis symptoms when used as the sole modality of treatment. When comparing NSI to reflexology (placebo), no superiority was seen. However, it was observed that the cure rates were 91% and 63% for intranasal steroid spray and NSI, respectively. Saline is not as effective as an intranasal steroid (Havrey, 2007). In a randomized controlled trial (RCT) of 76 patients with history of frequent CRS, Rabago et al. (2002), tested whether daily NSI improves chronic sinusitis symptoms and decreases medication use. Seventy seven percent of the patients with frequent CRS had decreased symptoms and medication use. The study was not designed to compare interventions, and it wasnt blinded or placebo-controlled. However, it had 90.8% completion rate, intention-to-treat analysis, and significant improvement to CRS symptoms.Some patients with CRS respond well to antileukotriene therapy. In the United States, there are two classes of antileukotriene drugs approved. The first is a 5-lipoxygenase inhibitor that blocks an enzyme that forms leukotriens. A randomized placebo-controlled trial showed that 72% of patients with CRS with NPs had a significant reduction in nasal symptoms. Of the 101 patients who participated in this study, 50% had decreased polyp size and 60% no longer required corticosteroids after one moth of antileukotriene treatment (Snow, 2009). The most common side effects after using antileukotriene therapy are headache and shortness of breath. Many controlled trials show that it is an alternative therapy that provides patients with CRS with or without NPs that are considered intolerant of corticosteroid doses a possible solution. Patients who have seasonal allergic rhinitis may develop CRS if not treated properly. In fact, it is an important predisposing factor for CRS. In this case, most patients are recommended to use antihistamines that reduce sneezing, especially in CRS patients with NPs (Snow, 2009). Immunotherapy is another good solution for CRS patients with NPs. Immunotherapy is usually recommended when the cause is fungal mediated. In a retrospective analysis of 60 CRS patients, it was found that patients not receiving immunotherapy had been re-operated on 33% of the time, compared to 11.1% in those receiving immunotherapy, suggesting the potential benefit of immunotherapy in preventing recurrence of CRS (Bassichis, 2001).Commonly, patients with CRS who do not respond well to all medical treatments described above are considered for surgical treatment. It is very difficult to cure CRS cases with medical management alone, since most CRS cases are a combination of pathological and anatomical factors that helps in the inflammation and bacteria presence. There are many different surgical approaches that have been developed. Some are considered invasive and others less invasive. The first surgical method is called Endoscopic Sinonasal Surgery (ESS), also referred to as traditional sinus surgery. This technique is considered to be invasive since an opening is made from the inside of the mouth or through the skin of the face (near the cheeks). The main purpose of this technique is to remove some tissue that is blocking the sinuses and preventing the drainage. Sometimes a temporary opening is made to help sinus drainage and reduce the infection from the addition of more air going in and out of the sinus opening. Guerrerro et, al. (2007) carried out a study that included 110 patients who were treated by ESS for chronic rhinosinusitis with polyps between the years of 1999 and 2004. All the patients in this study had the same surgeon and were monitored for two years after the surgery. Multiple factors were taken into account before the surgery, such as asthma, allergies, previous surgeries, and many additional symptoms. Before performing the surgery, several general procedures were followed to diagnose patients with CRS: CT scan, classification of the sinuses area and the patients underwent treatment with topical steroids and systemic steroids and if no improvement was seen during the three months treatment, then surgery was performed (Guerrero, 2007). After the surgery, the patients were placed on tropical steroids for at least two years. Minor complications were observed, such as hemorrhaging during the surgery, synechia (aneyecondition where theirisadheres to thecornea orlens,) ecchymosis, and sepal perforation. Major complications included orbital haematoma, mucolele/mucopyocele, fistulas of cerebrospinal fluid (CSF), and haemorrhaging that required post-surgical interpretations (Guerrero, 2007). For almost all the patients, it seems that endoscopic surgery was successful; however, there were many major or minor side effects. A follow up questionnaire of 110 patients showed, 75% had a better general condition: 77% in males and 71% in females. Their quality of life improved dramatically and only 12.6% had a revision due to severe cases.

Table 1: Questionnaire follow-up after surgery (Guerrero, 2007).

Two alternative surgical techniques to ESS are Functional Endoscopic Sinonasal Surgery (FESS) with maxillary sinus aspiration and irrigation and adenoidectomy (MSI), and endoscopically guided middle meatus cultures (EGC). MSI helps doctors to obtain cultures for microbial screening to help guide antibiotic therapy. MSI also helps by irrigating the mucous trapped within sinuses. However, MSI is not without risks as it is essentially a blind procedure. Risks include pseudoproptosis of the eye during irrigation of the maxillary sinuses and severe nasal bleeding that may require nasal packing (Deckard, 2011). Investigators from Wayne State University, Department of Otolaryngology, Head and Neck Surgery reviewed medical records from January 2004 to June 2010. In this retrospective study, all patients were diagnosed with CRS, which was defined as the presence of heavy nasal discharge, nasal congestion, heavy mucus secretions confirmed by rhinoscopy; finally, if they failed a broad spectrum oral antibiotics for at least 3 weeks. After the confirmation of CRS in those patients, some underwent either bilateral maxillary sinus aspiration & irrigation with adenoidectomy (MSI) or endoscopically guided middle meatus cultures & antral biopsy with adenoidectomy (EGC). MSI and EGC were performed under general anesthesia. For MSI patients, the sinuses were entered using a sterile trocar. The aspirated contents of the sinuses were sent for culture. After this, isotonic saline was used to irrigate the sinuses. For EGC patients, the middle meatus was cultured using a culture swab (a curved anteroposterior passage in each nasal cavity that is situated below themiddle nasal concha). After this, both the swab and a tissue sample were sent for culture and sensitivity. The removal of pharyngeal tonsils was performed, adenoidectomy, and hemostasis was achieved in all patients (Deckard, 2011). After the surgery, the patients were prescribed oral antibiotics, such as high doses of amoxicillin 90mg/kg per day, and cefuroxime 30mg/kg per day, or amoxicillin/clavulanate 45 mg/kg per day, depending on physicians preference (Deckard, 2011). When the patients reported that they did not have symptoms for at least two weeks, then the antibiotics were discontinued and if the symptoms did not come back again two weeks after discontinuing the antibiotics then the surgery was considered to be successful. Both techniques had similar results. The patient populations were statistically similar in all aspects: symptoms duration and time presentation. Moreover, the complications after the surgery were minimal in both groups. One patient in the MSI group developed nose bleed while introducing the trocar into the maxillary sinus, which required packing for a couple of days. Another two MSI patients developed pseudoproptosis, which spontaneously resolved. On the other hand, no complications or adverse events were observed in the patients that underwent EGC. Since the results of both techniques were similar, and endoscopically guided middle meatus cultures are considered to be much safer than MSI, EGC is recommended over MSI since it's less invasive to the sinonasal mucosa with similar or better patients outcome.

Diagram 2: Catheter-based dilation of sinus ostium is illustrated in obstructed sinus (Brown, 2006).

Balloon sinuplasty dilatation (BSD) is a new technology used as an adjunct to more conventional functional endoscopic sinus surgery (FESS) techniques. A guidewire, guided balloon catheter, and irrigation catheter is used in this technique. The surgeon should choose the catheter and balloon size best suited to the sinuses to ease the procedure. Also, a superb visualization of the middle meatus should be achieved before initiating the procedure (Sikand, 2011). The catheter should be preloaded with sinus illumination system and the balloon before its introduction to the nasal cavity (this should be done with the aid of endoscopic visualization). The system is then advanced into the sinus opening and pressure applied to inflate the balloon (usually 12 atm is sufficient). Sometimes multiple inflations are needed if the initial 12 atm was not sufficient to widen the sinus opening. Then, the sinus is flushed with the tube that was attached to the system that entered the sinus opening. After the procedure, the patients are sent home using antibiotics similar to the previous techniques. The benefit of this technique is that the patients could return to normal activities within 24 hours after the procedure. Moreover, little or mild pain was described by few patients and most of the patients indicated that the procedure was well tolerated. Successful ostial dilation was obtained in 9 of 10 patients (Sikand, 2011). In this study, the number of patients was limited and also lack of randomization, but overall it is considered to be one of the safest surgical techniques known so far to treat chronic rhinosinusitis, it is tolerable, and effective. To decrease the cost, the recovery time, and avoiding general anesthesia, office based BSD is a great solution (Sikand, 2011). Hopkins C. et al. (2006) performed a retrospective case note review of 27 patients undergoing BSD. The 27 patients were selected after they have failed to improve on a medical regimen of intranasal steroids, and low-dose macrolide antibiotics. In contrast to Sikand et al., (2011) this study had two different surgeons and 26 patients underwent general anesthesia. Dilatation was successful in 98 percent of sinuses in which it was attempted; however, only 62 percent of the patients noted improvement to their usual CRS symptoms.

Diagram 3: BSD in situ (Brown, 2006).Discussion:

Chronic sinusitis is a disorder of multi-factorial origin with contribution from various etiologies such as microbes, allergy, environmental, and anatomical. Our understanding to the pathophysiology of CRS has helped us improve treatment options. However, understanding the mechanisms of the development of chronic rhinusinusitis is still limited; therefore, selecting a treatment option for CRS is still challenging. No single hypothesis currently explains interplay of infectious and inflammatory stimulation in CRS patients. Further research would definitely improve our understanding of the underlying mechanisms and pathophysiology of CRS. In the meantime, patients who are diagnosed with chronic sinusitis, the first line of treatment would be antibiotics for two weeks or more. This will help reduce the infection that could be caused by bacteria. After treating the patient with multiple courses of antibiotics for a long period of time without any significant success in reducing the symptoms of chronic sinusitis, then the next line of treatment would be systemic corticosteroid therapy. Long-term treatment with corticosteroids may cause minor structural changes or even thinning of the epithelium; however, it is still very important modality in managing CRS and should be offered to all patients with CRS because of inhibition to inflammatory mediators (Desrosiers, 2011). In addition to the above solutions, nasal saline irrigation is beneficial in the treatment of chronic sinusitis symptoms when used as the sole modality of treatment (Havrey, 2007). Rabago, 2002; et al., study showed that NSI improves chronic sinusitis symptoms and decreases medication use in many patients. Alternatively, an RCT placebo-controlled experiment conducted by Snow et al. (2009), showed that 72% of patients with CRS with NPs had a significant reduction in nasal symptoms when treated with antileukotriene therapy. Of the 101 patients who participated in this study, 50% had decreased polyp size and 60% no longer required corticosteroids after one moth of antileukotriene treatment. However, many patients complained from side effects such as headache and shortness of breath. Further research may be warranted to answer questions and optimize antileukotriene therapy in practices to manage CRS symptoms. Patients who have seasonal allergic inflammation may develop CRS if not treated properly. In this case, most patients are recommended to use antihistamines that reduce sneezing, especially in CRS patients with NPs (Snow, 2009). When patients do not respond well to all medical treatments described above, they are considered for surgical treatment. It is very difficult to cure CRS cases with medical management alone, since most CRS cases are a combination of pathological and anatomical factors that helps in the inflammation and bacteria presence. Many different surgical approaches have been developed. Some are considered invasive and others less invasive. Guerrerro et, al. (2007) carried out a study that includes 110 patients who were treated by ESS for chronic rhinosinusitis with polyps. For almost all the patients, it seems that endoscopic surgery was successful; however, there were many major or minor side effects. After sending a follow up questionnaire to 110 patients, 75% had a better general condition, their quality of life improved dramatically and only about 12.6% had a revision due to severe cases. Maxillary sinus aspiration & irrigation with adenoidectomy (MSI) followed by an extended course of oral antibiotics has been shown to be an alternative to functional endoscopic sinus surgery. However, since MSI is not performed under direct visualization, it has inherent risk. A retrospective study by the Department of Otolaryngology Head & Neck Surgery at Wayne State University analyzed the techniques of MSI and endoscopically guided middle meatus cultures & antral biopsy with adenoidectomy (EGC). MSI identified bacteria in 80% of patients compared to 73% in EGC patients . The MSI group underwent antibiotic treatment for 8.7 weeks and achieved symptom resolution in 8.7 weeks compared to 6.9 weeks and 4.9 weeks respectively in the EGC group. However, the time of resolution of CRS symptoms was significantly lower in patients undergoing EGC versus MSI. EGC is an effective treatment for patients with CRS. EGC and MSI are equally effective in obtaining diagnostic cultures. EGC decreases time to symptom resolution, and it lowers the risk of complication when compared to MSI (Deckard, 2011). Balloon sinuplasty dilatation (BSD) is a new technology used as an adjunct to more conventional functional endoscopic sinus surgery (FESS) techniques. In particular, there have been no blinded, randomized, controlled studies comparing BSD with the current FESS. However, a number of groups have published non-randomized, controlled trials, and some retrospective case series with great outcomes. Hopkins C. et al. (2006) Performed a retrospective case note review of 27 patients undergoing BSD. The 27 patients were selected after they have failed to improve on a medical regimen of intranasal steroids, and low-dose macrolide antibiotics. Dilatation was successful in 98 percent of sinuses in which it was attempted; however, only 62 percent of the patients noted improvement to their usual CRS symptoms. In addition, Levine et al. (2008) reported a retrospective chart review of 1036 patients (3276 sinuses) undergoing sinuplasty in 27 centers. Ninety-six per cent of patients reported an improvement in symptoms, and 73 per cent reported they were free from symptoms during a mean follow-up period of 40 weeks. Although this large study lacked objective symptom measurement, the absence of reported complications supports the safety of the procedure. There is a great need for improved therapies to combat this frustrating chronic illness. Considerable effort, and additional time, will be required to collect complete data on CRS patients to intensify the treatment procedures in the future for better results. Conclusion:

Based on the research findings and comparing different types of treatments, such as antibiotics, corticosteroids, and multiple surgery types, the best treatment for chronic rhinosinusitis would be a mix of multiple therapies. In almost all cases, corticosteroids should be given to all CRS patients due to its anti-inflammatory role that is also effective in almost all inflammatory conditions. They help reduce the polyp size and also reduce swelling of the mucous membrane. In addition, corticosteroids inhibit inflammatory mediators which lead to a decrease in inflammation due to decreased vessel permeability and cell influx. Nasal saline irrigation (NSI) facilitates the removal of crust, and mucus and it is believed to help to remove infective agents and inflammatory mediators (Desrosiers, 2011). Although minor side effects are common, the beneficial effect of saline appears to outweigh these drawbacks for the majority of patients. The use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis. Patients with CRS who do not respond well to all medical treatments are considered for surgical treatment. Endoscopic sinus surgery (ESS) is widely accepted as an efficacious method to relieve sinus obstruction and treat the problem of CRS. However, problems still occur with ESS. Circumferential scarring can limit the ability of sinus openings to remain patent. Bleeding can obscure inoperative visualization. Orbital injury and accidental penetration of the brain are possible. The best functional endoscopic sinus surgery is Balloon sinuplasty dilatation. BSD provides a safe means of opening the sinuses, with less post-operative scarring. Another advantage of balloon sinuplasty is its capacity to be performed under local anesthesia. Many patients tolerated the dilatation with minimal transient discomfort. References:Bassichis, B.A.; Marple, B.F.; Mabry, R.L.; Newcomer, M.T.; Schwade, N.D. Use of immunotherapy in previously treated patients with allergic fungal sinusitis. Otolaryngol. Head Neck Surg., 2001, 125, 487-490.Brown, Christopher L., MD, and William E. Bolger, MD. "Safety and Feasibility of Balloon

Catheter Dilation of Paranasal Sinus Ostia: A Preliminary Investigation."Annals of Otology. Rhinology & Laryngology115.4 (2006): 293-99.

Catalano, P. "The Minimally Invasive Sinus Technique: Concepts and Controversies."Operative

Techniques in Otolaryngology-Head and Neck Surgery17.3 (2006): 189-96.De Sutter A.Legent F, Bordure P, Beauvillain C, Berche P. A double-blind comparison of ciprofloxacin and amoxicillin/clavulanic acid in the treatment of chronic sinusitis.Chemotherapy40(Suppl. 1),815(1994). Lemiengre M, Van Maele G, van Driel M, De Meyere M, Christiaens T, et al.

Predicting prognosis and effect of antibiotic treatment in rhinosinusitis.Ann Fam Med. 2006 Nov-Dec;4(6):486-93.Desrosiers, Martin. "Canadian Clinical Practice Guidelines for Acute and Chronic

Rhinosinusitis."Allergy, Asthma & Clinical Immunology(2011): 1-38.

Deckard, Nathan A., Gregory J. Kruper, Thi Bui, and James Coticchia. "Comparison of Two

Minimally Invasive Techniques for Treating Chronic Rhinosinusitis in the Pediatric Population."International Journal of Pediatric Otorhinolaryngology75.10 (2011): 1296-300.

Guerrero, Jossana, Beatriz Molina, Lorena Echeverra, Ignacio Arribas, and Teresa Riveraa.

"Endoscopic Sinonasal Surgery: Study of 110 Patients With Nasal Polyposis and Chronic Rhinosinusitis."Acta Otorrinolaringol(2007): 252-58.

Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database of Systematic Reviews. 2007;(3): CD006394. http://www2.cochrane.org/reviews/en/ab006394.html.

Hoover, G., L. Newman, T. Plattsmills, C. Phillips, C. Gross, and L. Wheatley. "Chronic

Sinusitis: Risk Factors for Extensive Disease."Journal of Allergy and Clinical Immunology100.2 (1997): 185-91.

Hopkins C, Browne J, Slack R, Brown P, Lund V, Copley L et al. The National Comparative Audit of Surgery for Nasal Polyposis and Rhinosinusitis. Clin Otol 2006;31:3908Legent F, Bordure P, Beauvillain C, Berche P: A double-blind comparison of

ciprofloxacin and amoxicillin/clavulanic acid in the treatment of chronic

sinusitis. Chemotherapy 1994, 40(Suppl 1):8-15.Levine HL, Sertich AP, Hoisington D, Weiss R, Pritikin J. Multicenter registry of balloon catheter sinusotomy outcomes for 1,036 patients. Ann Otol Rhinol Laryngol 2008;117:26370

Namyslowski, A double-blind comparison of cefuroxime and amoxicillin/clavulanic acid in the treatment of chronic sinusitis. Chemotherapy 2004, 2-14.

Rosenfeld, R. "Clinical Practice Guideline on Adult Sinusitis."Otolaryngology - Head and Neck

Surgery137.3 (2007): 365-77.

Sikand, Ashley, MD. "Introduction to an Office-based Sinus Surgery Technique."Operative Techniques in Otolaryngology(2011)): 246-52.

Snow, James B., Phillip A. Wackym, and John Jacob Ballenger.Ballenger's

Otorhinolaryngology: Head and Neck Surgery.Shelton, CT: People's Medical Pub. House/B C Decker, 2009: 573-582.

Thottam, Prasad John, Michael Haupert, Sonal Saraiya, James Dworkin, Ranga Sirigiri, and

Walter M. Belenky. "Functional Endoscopic Sinus Surgery (FESS) Alone versus Balloon Catheter Sinuplasty (BCS) and Ethmoidectomy: A Comparative Outcome Analysis in Pediatric Chronic Rhinosinusitis."International Journal of Pediatric Otorhinolaryngology76 (2012): 1355-360.Diagram 1 picture: http://en.wikipedia.org/wiki/File:Nnh_front.svg. April, 2013 date taken.Videler WJ, Badia L, Harvey RJet al. Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial.Allergy66(11),14571468(2011).

Wallwork B, Coman W, Mackay-Sim A, Greiff L, Cervin A. A double-blind, randomized, placebo-controlled trial of macrolide in the treatment of chronic rhinosinusitis.Laryngoscope116(2),189193(2006).Fady Banno30586 Fox Club Drive,

Farmington Hills, MI 48331,

(248)-961 2232,

fbanno@med.wayne.edu.

a. Professional Preparation Wayne State University, Undergrad Institution

B.S. Biology, Year 2011

Wayne State University School of Medicine Grad Institution M.S., Masters of Sciences

(2011-Present)

b. Publications

Jeffrey L. Ram, Aos S. Karim, Fady Banno and Donna R. Kashian, 2011. Invading the invaders: reproductive and other mechanisms mediating the displacement of zebra mussels by quagga mussels.

Jeffrey L. Ram, Fady Banno, Richard R. Gala, Jason P. Gizicki, and Donna R. Kashian. Benthic Invertebrates in the Toledo Harbor region of Lake Erie