ARS COSM 2-2013d - American Rhinologic

April 12-13, 2013JW Marriott Grande Lakes, Orlando, FL

www.american-rhinologic.org

2013cosmP R O G R A M & A B S T R A C T S

3www.american-rhinologic.org

Presidential Welcome to the ARS at COSM 2013

On behalf of the Board of Directors, it is my great honor and pleasure to welcomeyou to the American Rhinologic Society meeting at COSM in beautiful Orlando.Under the direction of Program Chairman, Tim Smith, MD, and his programcommittee, we once again hope to offer an exciting, valuable and enjoyableprogram. It is our sincere goal to provide program content that is broad and timelyas we recognize the wide array of interests and needs amongst our membership.On display during this program will be unparalleled scientific research, clinicallyrelevant panel discussions, and invited speakers sharing their experiences. It is mysincere goal to help the ARS become a society that appeals to all otolaryngologistswith interest in the field of rhinology.

I continue to marvel at the generosity our corporate partners exhibit in support ofour organization and its endeavors. It is only through these strong relationships thatwe are able to realize our lofty goals of excellence in education, training, research,and patient advocacy. On behalf of the entire Board of Directors, I am proud to saythat these partnerships are stronger than ever with aligned strategic goals. Pleasejoin me in thanking our corporate partners by exploring the exhibits and visiting withthem.

I believe this COSM will prove to be our finest yet as an organization. Please enjoy your time in Orlando and welcome to the ARS.

Todd T. Kingdom, MDPresident, American Rhinologic Society

Todd Kingdom, MD

4 American Rhinologic Society

Program Chair Welcome Welcome to the ARS at COSM Orlando!

I would like to welcome you to the ARS at COSM Orlando 2013! The ARS isproud to provide this educational program to serve our members, allotolaryngologists, and allied health care providers from throughout the UnitedStates, North America, and the world.

At the ARS, we have worked very hard to arrange a program that hassomething for everyone. We've developed clinical debates, moderated panelsthat address the most pressing issues in our field, and a scientific program thatis state-of-the-art, well rounded, and highly educational.

It is our sincere hope that there is “something outstanding” in this program forevery attendee. Thank you for your continued support of the AmericanRhinologic Society. Please seek me out and provide me with your criticalfeedback about the program.

I”ll see you at our corporate partners coffee break!

Tim L. Smith, MD, MPHARS President-Elect & Program Chair

P.S. If you think the ARS at COSM Program is great, wait until you see theprogram for the ARS at AAO-HNS September 28, 2013 in Vancouver, BC!Please save the date! Highlights include:

• Panel: What is Happening in the World of Rhinology: An International Forum of Allergy & Rhinology

• Panel: An Insightful Discussion: In hindsight, I would have handled this differently. Lessons learned the hard way…

• The 9th Annual Kennedy Lecture - Berrylin J. Ferguson, MD: Twenty-five Years of Sinus Study: Learning and Unlearning

• Showcasing ARS Research and The International Forum of Allergy & Rhinology

• ARS/AAOA Combined Panel: Changing Your Practice: Strategies to Manage Your Patients with Recalcitrant Rhinosinusitis

• Join your colleagues to discuss the latest advances in our field and discuss your challenging cases!

• Explore the exhibits of our Industry Partners where the latest technology is unveiled!

Timothy Smith, MD


Todd Kingdom, MDPresident University of Colorado School of Medicine12631 E. 17th Avenue, #B205Aurora, CO 80045Tel: 303-724-1960Fax: 303-724-1961Email: [email protected]

Michael Setzen, MDImmediate Past President 600 Northern Blvd., Suite 312Great Neck, NY 11021Tel: 516-829-0045Fax: 516-829-0441Email: [email protected]

Timothy Smith, MDPresident ElectOregon Health & Science UniversityOregon Sinus Center3181 SW Sam Jackson Park Rd PV- 01Portland, OR 97239Tel: 503-494-7413Fax: 503-494-4631Email: [email protected]

James Palmer, MDSecretaryUniversity of Pennsylvania Medical Center5 Ravdin, Division of Rhinology3400 Spruce StreetPhiladelphia, PA 19104Tel: 215-662-7746Fax: 215-614-0071Email: [email protected]

Joseph B. Jacobs, MDTreasurerNYU Medical Center345 E. 37th Street #306New York, NY 10016Tel: 646-754-1202Fax: 646-754-1222Email: [email protected]

Roy Casiano, MDFirst Vice PresidentUniversity of Miami Hospitals & Clinics1120 NW 14th Street5th floor, Clinical Research BldgMiami, FL 33136Tel: 305-401-7088Email: [email protected]

Peter Hwang, MDSecond Vice President801 Welch RoadStanford, CA 94305Tel: 650-725-6500Fax: 650-725-8502Email: [email protected]

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

American Rhinologic Society Executives - 2013


ARS Board of Directors

Consultants to the Board

Pete Batra, MD Marc Dubin, MD

Joseph Han, MD Robert Kern, MD

Ralph Metson, MD

Michael Stewart, MD

John DelGaudio, MD

Rodney Schlosser, MD

Parul Goyal, MD

Sarah Wise, MD


Chairs

Audit Subinoy Das, MD

By-LawsDouglas Reh, MD

Business DevelopmentJoseph Jacobs, MD

CMERaj Sindwani, MD

EthicsMark Zacharek, MD

Information TechnologyKevin Welch, MD

International LiaisonNicolas Busaba, MD

Patient AdvocacySeth Brown, MD

Pediatric RhinologyHassan Ramadan, MD

NewsletterSarah Wise, MD

EducationRick Chandra, MD

AwardsDavid Poetker, MD

FellowshipTodd Kingdom, MD

MembershipChristopher Melroy, MD

Resident/FellowsBellachew Tessema, MD

Research GrantsNoam Cohen, MD

HistorianEugenia Vining, MD


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, MD2009 - 2010 Stilianos Kountakis, MD2010 - 2011 Brent A. Senior, MD2011 - 2012 Michael Setzen, MD2012 - 2013 Todd Kingdom, MD*Deceased

Past Presidents Secretaries2012 - present James Palmer, MD2009 - 2012 Peter Hwang, MD2005 - 2008 Brent A. Senior, MD1999 - 2005 Marvin P. Fried, MD1995 - 1999 Frederick Stucker, MD1990 - 1995 Frank Lucente, MD1985 - 1990 George Facer, MD1980 - 1985 Pat A. Barelli, MD1975 - 1980 Glenn H. Drumhiller, MD1970 - 1975 Ralph H. Riggs, MD


ARS Mission StatementThe American Rhinologic Society’s mission is to serve, represent and advance the science andethical practice of rhinology. The Society promotes excellence in patient care, research andeducation in Rhinology and Skull Base Disorders. The American Rhinologic Society is dedicatedto providing communication and fellowship to the members of the Rhinologic community throughon-going medical education, patient advocacy, and social programs. The ARS continuing medicaleducation activities serve to improve professional competence, performance, and promoteresearch.

Business/ACCME

Continuing EducationAccreditation StatementThe American Rhinologic Society is accredited by the Accreditation Council for ContinuingMedical Education to provide continuing medical education for physicians.

Credit Designation StatementThe American Rhinologic Society designates this live activity for a maximum of 10.25 AMA PRACategory 1 CreditsTM. Physicians should claim only the credit commensurate with the extent oftheir participation in the activity.

Goals and Objectives

At the conclusion of this meeting participants will be able to:

1. Discuss the latest information on the medical management of patients with chronicrhinosinusitis and other rhinologic diseases including allergic rhinitis.

2. Gain an understanding of the indications, procedural nuances and potential complications ofcontemporary surgical techniques used in nasal, endoscopic sinus, and skull base surgery.

3. Demonstrate awareness of emerging research examining the pathophysiology of chronicrhinosinusitis and other rhinologic diseases.


Welcome New ARS Members!September 2012 - February 2013

INTERNATIONAL MEMBERS

Julian Lee, MD, Singapore, Singapore

REGULAR MEMBERS

Ryan C. Case, MD, Brookhaven, MSSandra Ettema, MD, Galesburg, IL

Robert Mancuso, MD, Meza, AZLee Mandel, MD, Hollywood, FL

Rae McIntee, MD, Quincy, ILSamuel Pate, MD, Omaha, NE

Margaret J Provenza, MD, Rockford, ILJeremy Reed, MD, Harker Heights, Tx

Michael Rontal, MD, Bloomfield Hills, MIMajd Roufail, MD, Doha, Qatar

Matthew S. Russell, MD, San Francisco, CAVictor Scapa, MD, Kirkland, WA

Justin H. Turner, MD, Nashville, TNDouglas Worden, MD, Flemington, NJArthur W Wu, MD, Los Angeles, CAFazlur Zahurullah, MD, Rockford, IL

Adam M Zanation, MD, Chapel Hill, NC

RESIDENT MEMBERS

Yazeed Alghonaim, MD, Montreal, QuebecShawn Allen, MD, Memphis, TN

Jennifer Alyono, MD, Menlo Park, CARachel Arffa, MD, Temple, TX

Mary Ashmead, MD, Jackson, MSChristie Barnes, MD, South Burlington, VA

Mark Been, MD, Chicago, ILKevin Burke, MD, San Francisco, CA

Nadieska Caballero, MD, Park Ridge, ILNan Chen, MD, Columbia, MO

Adrienne Childers, MD, Richmond, VAMatthew Clavenna, MD, Shreveport, LA

Adam S. DeConde, MD, Santa Monica, CAJustin W. Douglas, MD, Morgantown, WV

Deepak Dugar, MD, Chapel Hill, NCMegan Durr, MD, San Francisco, CA

Mohamed Hegazy, MD, Damietta, DomiatCandace Hrelec, MD, Campbell, OH

Scott Hudson, MD, Salt Lake City, UTQasim Husain, BS, Fairlawn, NJ

Armon Jadidian, MD, Gainesville, FLAdam Kimple, MD, Chapel Hill, NC

Joshua M. Levy, MD, New Orleans, LAVictor Lin, MS, Fort Worth, TX

Jackie Matijasec, MD, Baton Rouge, LAWendy McConnell, MD, Saint Louis, MO

Rahul Mehta, MD, Baltimore, MDSarah Novis, MD, Ann Arbor, MI

James J. Owusu, MD, Minneapolis, MNCharles Parker, MD, Cincinnati, OH

Alkis Psaltis, MD, Palo Alto, CAShoib Sana, DO, Detroit, MI

Joseph Schwartz, MD, Montreal, QuebecPrateek Srinet, MD, New Haven, CT

Jacob Stelle, MD, Springfield, ILPatrick Stevens, MD, Hartford, CTAlexis Strohl, MD, Rochester, NY

Wade Swenson, MD, Minneapolis, MNTimothy Wong, MD, Gainesville, FLEdward Wu, MD, Diamond Bar, CA

William Yao, MD, Houston, TX


Floor Plan


Oral Presentations - At-A-Gance

COSM 2013Friday PM SessionAt-A-Glance1:00PMWelcomeARS President Todd Kingdom, MD and President-Elect Timothy L. Smith, MD, MPH

1:05PMPanel: Chronic Sinusitis from theAllergist/Immunologist Perspective:Immunotherapy, Steroids, ASADesensitization, Immunomodulators, andwhat Allergists expect from our surgery!

Moderator: Robert Kern, MDPanelists: *Larry Borish, MD; * Anju TripathyPeters, MD *Member, American Academy of Allergy,Asthma, and Immunology

Session: Inflammation in RhinosinusitisModerators: Devyani Lal, MD, Eugene Chang, MD

1:50PMIL-4 and IL-13 Compromise the SinonasalEpithelial Barrier and Perturb IntercellularJunction Protein ExpressionSarah K. Wise, MD

1:57PMP-glycoprotein is a Marker of TissueEosinophilia and Radiographic Inflammationin Chronic Rhinosinusitis without NasalPolypsRachel E. Feldman, BA

2:04PMThe In-Vivo Effect of Leptospermum Honeyon Cytokine Expression in CRS PatientsJamil Manji, BSc.H

2:11PM Differential Expression of VCAM and ICAMby Sinonasal Fibroblasts Among Control andChronic Rhinosinusitis PatientsSamuel L. Oyer, MD

2:18PMDiscussion/ Q&A

Session: Topical Therapies and DeliveryModerators: Karen Fong, MD, Luke Rudmik, MD

2:25PMBudesonide Nasal Irrigations in theManagement of Chronic RhinosinusitisDavid Jang, MD (Presented by Jamie Segel,MD)

2:32PMEffect of High Dose Intranasal Steroids onIntraocular PressureKristin Seiberling, MD (Presented by JustinMcClarty, MD)

2:39PMEffects of Intranasal Budesonide Deliveredby Nasal Nebulizer on Symptoms andObjective Measures of Nasal Congestion inPerennial Allergic Rhinitis Faud Baroody, MD

2:46PM The Effect of Head Position on Distributionof Topical Medication using the MucosalAtomization Device on the ParanasalSinuses: A Cadaver StudyAl-Rahim Habib, BSc

2:53PMDiscussion/Q&A

3:00PMBreak with Industry Partners

3:25PMUpdate on Etiology of CRS: Do Our SinusesCrave Certain Bacteria for Health?Invited Speaker: Andrew Goldberg, MD

Session: Rhinosinusitis: The Role ofBacteria Moderators: Pete Manes, MD, Erin O'Brien, MD

3:50PMImpact of Therapy on the CRS SinusMicrobiomeCindy Liu, MD, MPH



3:57PMThe Impact of Culturable BacterialCommunity on Histopathology in CRSDarren Rom, MD

4:04PMComparing Sinus and Pulmonary Cultures inPatients with Bronchiectasis and ChronicRhinosinusitisVijay Ramakrishnan, MD


4:18PMPanel: Everyday Struggles in Our Practices-Expert Solutions!Moderator: Donald Lanza, MDPanelists: John DelGaudio, MD; Todd Kingdom,MD; Marc Dubin, MD; Stacey Gray, MD

5:00PMClosing Remarks and Adjournment Timothy L. Smith, MD, MPH, President-Elect and Program Chair

_____________________________________

COSM 2013Saturday SessionAt-A-Glance8:00AMWelcomeTimothy L. Smith, MD, MPH, President-Elect and Program Chair

8:05AMPresidential Address Todd Kingdom, MD

Session: Surgical PracticesModerators: Greg Davis, MD, Zach Soler, MD

8:15AMOffice-Based Balloon Sinus Dilation: 52+Week Follow-up of a Prospective MulticenterStudyAshley Sikand, MD

8:22AMNovel Vacuum-Powered Microdebrider forOffice Polypectomy: A Case SeriesAmin Javer, MD.8:29 AMNasal Surgery for Obstructive Sleep Apnea-A Role for Endoscopic Sinus Surgery?Rohan Wijewickrama, MD

8:36AMA Comparison of Septal Stapler to SutureClosure in Nasal Septoplasty: A Prospective,Randomized Trial Evaluating the Effect onOperative Time and OutcomesLeigh Sowerby, MD

8:43AMDiscussion/Q&A

Session: Novel Research at the CuttingEdgeModerators: Vijay Ramakrishnan, MD,Ameet Singh, MD

8:50AMIdentification of Human Nasal MucosalEpithelial Stem CellsMrinmoy Sanyal, PhD

8:57AMDistribution of Human Nasal MesenchymalStem CellsBradley J. Goldstein, MD, PhD

9:04AMConstitutive Expression of VEGF GeneFamily Ligand and Receptors on HumanUpper and Lower Airway Epithelial CellsJean Kim, MD, PhD

9:11AM Anti-Inflammatory Mediators and SleepDysfunction in Chronic RhinosinusitisJeremiah Alt, MD, PhD


9:25AMPanel: Inferior Turbinate Reduction Surgery:Minimalist vs. Turbinator

Moderator: Pete Batra, MDPresenters: Roy Casiano, MD and Martin Citardi, MD


9:55AMBreak with Industry Partners

Session: Disease Manifestations andTreatment OutcomesModerators: Ayesha Khalid, MD, Abtin Tabaee, MD

10:25AMA Systematic Review and Meta-analysis ofAsthma Outcomes Following EndoscopicSinus Surgery for Chronic RhinosinusitisRishi Vashishta, MD

10:32AMSurgical Management of ChronicRhinosinusitis in Cystic Fibrosis: ASystematic ReviewJonathan Liang, MD

10:39AMOstiomeatal Occlusion Does Not Correlatewith Sinus Disease in EosinophilicRhinosinusitis* Dr Kornkiat Snidvongs*(PJ Wormald Research Award from AustralasianRhinologic Society)


Session: Treatment Outcomes and CostEffectivenessModerators: Jean Anderson Eloy, MD,Jamie Litvack, MD

10:53AMImpact of Continued Medical Therapy inPatients with Refractory ChronicRhinosinusitisKristine A. Smith, MD

11:00AMImpact of Symptom-Based RiskStratification on the Cost EffectiveDiagnosis of Patients with ChronicRhinosinusitis SymptomsBruce Tan, MD

11:07AMComparison of Outcomes of EndoscopicLigation and Endovascular Treatment ofSphenopalatine Artery for Epistaxis: A Five-year Series from a Single InstitutionNirav Thakkar, MD


11:19AMPanel: The Cutting Edge: From Lab Benchto Bedside - Improving Care for Our PatientsModerator: Ralph Metson, MDPanelists: Bruce Tan, MD; Sarah Wise, MD;Brad Woodworth, MD

12:00PMLunch Break with Industry Partners

Session: Steroids in Chronic RhinosinusitisModerators: Steve Pletcher, MD,Nathan Sautter, MD

1:00PMThe Effect of Intranasal FluticasonePropionate Irrigations on Salivary Cortisol,Intraocular Pressure, and PosteriorSubcapsular Cataracts in PostsurgicalChronic RhinosinusitisLi-Xing Man, MPA, MD, MSc

1:07PMWhen do the Risks of Repeated Courses ofCorticosteroids Exceed the Risks ofSurgery?Randy Leung, MD

1:14PMSystemic Prednisone AdministrationSelectively Alters Granulocyte Subsets inNasal Polyps from AERD and CRS PatientsJustin Edward, MS

1:21PMChronic Rhinosinusitis with Nasal Polyps isAssociated with Increased Nrf2 MediatedAntioxidant Gene ExpressionMurugappan Ramanathan, MD


Session: Management of CSF Leaks andOlfactionModerators: Nithin Adappa, MD,Jonathan Liang, MD

1:35PMAcetazolamide for High IntracranialPressure CSF LeaksMohamed R. Chaaban, MD


1:42PMPorcine Small Intestine Submucosal Graftfor Endoscopic Skull Base ReconstructionElisa Illing, MD

1:49PMInterferon Gamma Causes OlfactoryDysfunction Without ConcomitantNeuroepithelial DamageAndrew Lane, MD


2:03PMPanel: Evidence-based rhinology: How Hasthe Evidence Changed my Treatment ofSinonasal Disease?Moderator: Michael G. Stewart, MD, MPHPanelists: Jack Krouse, MD; Brent Senior, MD;David Poetker, MD; Stephanie Joe, MD


Session: Sinonasal and Skull Base TumorsModerators: Troy Woodard, MD and AdamZanation, MD

3:25PMEvolution in the Treatment of SinonasalInverted Papilloma: The Pedicle OrientedEndoscopic SurgeryAlessandro Pusateri, MD

3:32PMp16, EGFR, CyclinD1, and p53 StainingPatterns for Inverted PapillomaGiant Lin, MD

3:39PMQuality of Life Metrics after Surgery forSinonasal Neoplasms: Analysis ofPredictive FactorsNathan Deckard, MD

3:46PMSinonasal Quality of Life Outcomes afterMinimally Invasive Resection of Sinonasaland Skull Base TumorsBrian Harrow, MSII, BS


4:00PMRhinology 2013: What Does the Future Holdfor Rhinology/Sinus Surgery?Invited Speaker: David W. Kennedy, MD

Session: Clinical Practice Update: Is YourPractice Current?Moderators: Naveen Bhandarkar, MD and ErinWright, MD

4:25PMA Systematic Review of Non-absorbable,Absorbable and Medicated SpacersFollowing Endoscopic Sinus SurgeryXiao Zhao, MD

4:32PMSystematic Review and Meta-analysis ofTotal Intravenous Anesthesia andEndoscopic Sinus SurgeryAdam DeConde, MD

4:39PMThe Impact of Neo-Osteogenesis on DiseaseControl in Chronic Rhinosinusitis afterPrimary SurgeryPeta-Lee Sacks, MS

4:46PMAspirin Desensitization for Samter's TriadNasal Polyposis: A Systematic ReviewJason Xu, MSc


5:00PMClosing Remarks & Meeting Adjourned - President and President-Elect: Todd Kingdom,MD and Timothy L. Smith, MD, MPH

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COSM 2013Friday PM SessionProgram DetailsFriday, April 12, 2013JW Marriott Grande Lakes OrlandoMediterranean 5

1:00PMWelcomeARS President Todd Kingdom, MD, President-Elect Timothy L. Smith, MD, MPH

1:05PMPanel: Chronic Sinusitis from theAllergist/Immunologist Perspective:Immunotherapy, Steroids, ASADesensitization, Immunomodulators, andwhat Allergists expect from our surgery!

Moderator: Robert Kern, MDPanelists: *Larry Borish, MD; * Anju TripathyPeters, MD*Member, American Academy of Allergy, Asthma, andImmunology

Session: Inflammation in RhinosinusitisModerators: Devyani Lal, MD and EugeneChang, MD

1:50PMIL-4 and IL-13 Compromise the SinonasalEpithelial Barrier and Perturb IntercellularJunction Protein ExpressionSarah Wise, MD, Adrienne Laury, MD,Elizabeth Katz, MD, Kyle Den Beste, BACharles Parkos, MD, PhD, Asma Nusrat, MDAtlanta, GA USA

Introduction: Altered expression of epithelial intercellularjunction proteins have been observed insinonasal biopsies from nasal polyps andepithelial layers cultured from AFRS patients.These alterations comprise a "leaky" epithelialbarrier phenotype. We hypothesize that Th2cytokines IL-4 and IL-13 modulate epithelialjunction proteins thereby contributing to theleaky epithelial barrier.

Methods: Differentiated, ciliated, primary sinonasalepithelial layers cultured at the air-liquid inter-

face were exposed to IL-4, IL-13, and controlsfor 24 hours at 37C. Epithelial resistance meas-urements were taken every 4 hours duringcytokine exposure. Western blot and immuno-fluorescence staining/confocal microscopy wereused to assess changes in a panel of tight andadherens junction proteins. Western blot densit-ometry was quantified with image analysis.

Results: IL-4 and IL-13 exposure resulted in a meandecrease in transepithelial resistance at 24hours to 51.6% (n=6) and 68.6% (n=8) of base-line, respectively. Tight junction protein JAM-Aexpression decreased 42.2% with IL-4 expo-sure (n=9) and 37.5% with IL-13 exposure(n=9). Adherens junction protein E-cadherinexpression decreased 35.3% with IL-4 expo-sure (n=9) and 32.9% with IL-13 exposure(n=9). Tight junction protein claudin-2 increased27.0% with IL-4 exposure (n=5) and 53.2% withIL-13 exposure (n=5). There were no apprecia-ble changes in claudin-1, occludin, or ZO-1 withIL-4 or IL-13 exposure.

Conclusion: Sinonasal epithelial exposure to Th2 cytokinesIL-4 and IL-13 results in alterations in intercellu-lar junction proteins JAM-A, claudin-2, and E-cadherin, reflecting increased epithelial perme-ability. Such changes may explain some of thephenotypic manifestations of Th2-mediatedsinonasal disease, such as edema, nasal dis-charge, and environmental reactivity.

1:57PMP-glycoprotein is a Marker of TissueEosinophilia and Radiographic Inflammationin Chronic Rhinosinusitis without NasalPolypsRachel Feldman, BA, Allen Lam, MD, PeterSadow, MD, PhD, Benjamin Bleier, MD, Boston, MA USA

Introduction: P-glycoprotein(P-gp) is a membrane boundefflux pump which is upregulated in chronic rhi-nosinusitis with nasal polyps(CRSwNP) andparticipates in epithelial cytokine secretion.Eosinophilic Chronic Rhinosinusitis(ECRS)shares a similar cytokine profile with CRSwNPand is associated with significant inflammationand poor surgical outcomes. The goal of this

Oral Presentations - Program Details


study is to determine if P-gp expression corre-lates with degree of eosinophilia and severity ofradiographic inflammation in patients with CRSwithout polyps(CRSsNP).

Methods: IRB approved study utilizing sinus tissue in 28steroid naïve patients with CRS. P-gp expres-sion was calculated using quantitative fluores-cent immunohistochemistry(Q-FIHC) to gener-ate an epithelial to background staining ratio.Patients were stratified into low and highepithelial expression groups(<3 and =3, respec-tively). Average eosinophils per high poweredfield(hpf) and Lund-Mackay scores were calcu-lated and compared with P-gp staining ratiosusing a 2-tailed Student's t-test.

Results: Among the 28 patients, 4(14.29%) had high P-gp expression ratios(mean+/-SD, 4.94+/-1.81)while 24(85.71%) had low expressionratios(1.91+/-0.49). The number of eosinophilsper hpf were significantly greater in the high P-gp expression group as compared to the lowexpression group(36.10+/-39.40 vs. 6.39+/-11.40, p=0.004). The Lund-Mackay scores weresignificantly greater in the high P-gp expressiongroup as compared to the low expressiongroup(12.50+/-3.70 vs. 7.29+/-4.75, p<0.05).

Conclusions: P-gp is known to be overexpressed inCRSwNP. This preliminary study suggests thatamong patients with CRSsNP, P-gp is similarlyoverexpressed in those with high tissueeosinophilia and correlates with severity of radi-ographic inflammation.

2:04PMThe In-Vivo Effect of Leptospermum Honeyon Cytokine Expression in CRS PatientsJamil Manji, BSc.H, Andrew Thamboo, MD,San V. Sunkaraneni, DO, Cathie Garnis, Ph.D,,Amin Javer, MD, Vancouver, BC

Background: Leptospermum (Manuka) Honey (LH) is a natu-ral anti-inflammatory and antimicrobial agent.Leptospermum Honey (LH) nasal irrigation hasbeen demonstrated to be effective in improvingsymptoms in a subgroup of ChronicRhinosinusitis (CRS) patients. Currently, the

effect of LH on tissue has only been studied in-vitro.

Objective: To compare the cytokine expression profile oftissue from patients receiving daily LH irrigationversus normal saline for three months followingsinus surgery.

Methods: Patients with CRS and enrolled in a random-ized control trial of LH irrigation on postopera-tive outcomes were chosen. Tissue biopsieswere collected over a three-month course oftreatment following functional endoscopic sinussurgery. The Bio-Rad suspension array systemwas used to measure the concentration of sev-enteen cytokines on a Luminex platform. Dataanalysis was performed with a permutation testfor non-parametric data and Benjamin andHochberg method for multiple testing.

Results: Tissue samples from twenty-two patients werecollected. When compared to control patients,four cytokines were significantly elevated(CI=99%) in tissue from the LH group afterthree months of treatment: IL-6 (p=8.56E-5), IL-8 (p=3.25E-4), IL-13 (p=1.97E-4), and MCP-1(p=2.21E-4). This pattern was similarly reflectedbetween groups after 5-weeks of treatment.

Conclusion: eptospermum (Manuka) Honey has the effect ofup-regulating IL-6, IL-8, IL-13, and MCP-1 insinonasal epithelial tissue.

2:12PM Differential Expression of VCAM and ICAMby Sinonasal Fibroblasts Among Controland Chronic Rhinosinusitis PatientsSamuel Oyer, MD, Rodney Schlosser, MD,Jennifer Mulligan, PhD, Charleston, SC

Background: Chronic rhinosinusitis (CRS) is characterized byinflammatory cell migration into sinus tissuewith resultant inflammation fueled by a milieu ofcytokines. Fibroblasts may play a role in direct-ing inflammation through expression of vascularcell adhesion molecule (VCAM) which attractseosinophils and mast cells and may contributeto Th2 skewing, and intercellular adhesion mol-


ecule (ICAM) which attracts neutrophils and toa lesser degree, eosinophils, and may con-tribute to mixed Th1/Th2 skewing. The purposeof this study is to compare sinus fibroblastadhesion molecule expression in vivo amongCRS subtypes and in vitro following cytokinestimulation.

Methods: Sinus biopsies were taken from control patients(n=13), chronic rhinosinusitis without polyps(CRSsNP, n=6), and with polyps (CRSwNP,n=15). In vivo VCAM and ICAM were meas-ured by flow cytometry from single cell suspen-sions of tissue biopsies. Changes in VCAMand ICAM expression to cytokine exposure wasassessed using in vitro cultured sinonasalfibroblasts treated with TNF-a, IL-4, or IFN-?.

Results: In vivo VCAM expression was lowest in con-trols, higher in CRSsNP, and highest inCRSwNP. In vitro stimulation with TNF-a andIL-4, but not IFN-?, increased VCAM amongCRSsNP, while expression in CRSwNPremained elevated with all treatments exceptIFN-?. In vivo ICAM expression was elevatedin both CRS subtypes. In vitro stimulation withTNF-a and IFN-?, but not IL-4, increased ICAMexpression in all patients with the largest effectsamong the CRSsNP subgroup.

Conclusions: Sinonasal fibroblast expression of adhesionmolecules varies by disease state and is selec-tively influenced by exposure to inflammatorycytokines.

2:18PMDiscussion/ Q&A

Session: Topical Therapies and DeliveryModerators: Karen Fong, MD, Luke Rudmik, MD

2:25PMBudesonide Nasal Irrigations in theManagement of Chronic RhinosinusitisDavid Jang, MD, Vasileios Lachanas, MD,Stilianos Kountakis, MD, Augusta, GA

Objective:To demonstrate that budesonide nasal irriga-tions (BNI) improve quality of life and

endoscopy scores in patients with chronic rhi-nosinusitis (CRS)

Study Design:Retrospective review of prospectively-collecteddata.

Methods:We identified sixty patients who were pre-scribed BNI postoperatively, but had a lapse intherapy for a minimum of one month. Thetwenty-item sinonasal outcomes test (SNOT-20)and Lund-Kennedy endoscopy scores with BNIand without BNI were compared using pairedanalyses, controlling for administration of oralsteroids tapers. All patients were prescribedconventional nasal steroids, a leukotrieneinhibitor, and nasal saline irrigations. Bothparametric (paired t-test) and non-parametric(Wilcoxon test) analyses were performed.

Results:Thirty patients had eosinophilic chronic rhinosi-nusitis with polyps (eCRSwNP), thirteen hadallergic fungal sinusitis (AFS), thirteen hadSamter’s triad (ST), and four had eosinophilicchronic rhinosinusitis without polyps(eCRSsNP). Mean follow-up time was 36months. 55% of patients had lower SNOTscores (mean difference 8.8), and 56% hadlower endoscopy scores with BNI (mean differ-ence 3.4). SNOT-20 scores were significantlyimproved with BNI on paired t-test analysis(p=0.048). Endoscopy scores were significantlyimproved in the eCRS group (p=0.019). Non-parametric analysis yielded no significant differ-ences with BNI.

Conclusion:The addition of BNI is beneficial in the treat-ment of patients with inflammatory CRS.

2:32PMEffect of High Dose Intranasal Steroids onIntraocular PressureKristin Seiberling, MD, Christopher Church, MD,Dennis Chang, MD, Janice Nyirady, NP,Francine Park, MS, Loma Linda, CA

Objective: Intranasal and oral corticosteroids are widelyused in the management of chronic rhinosinusi-tis with nasal polyps (CRSwNP). High dose


topical steroids (HDTS) (budesonide, dexam-ethasone) are increasingly used for long-termmaintenance in these patients. Oral steroidshave the potential to cause increased intraocu-lar pressure (IOP) and glaucoma. It is unclearwhether HDTS have the same potential. Theobjective of this study is to determine the effectof HDTS on IOP.

Methods: Two groups of patients with CRSwNP treatedwith HDTS (budesonide or dexamethasone)were prospectively enrolled. Patients with histo-ry of elevated IOP or glaucoma were excluded.Group one consisted of patients who had beenon HDTS at the time of enrollment for at least amonth. Group two consisted of patients whowere placed on HDTS at the time of enrollment.For group one, IOP was measured once, atenrollment. Group 2 had IOP measured bothbefore and after 4 weeks of therapy.

Results: Nineteen patients in group 1 and 9 patients ingroup 2 completed the study. In group 1, theaverage duration of therapy was 7.4 months (1-30 months). Sixteen patients in group 1 hadnormal IOP. In 3 patients there were 3 singleeye pressures measured over 20 mmHg. Noneof the patients in group 2 had a significantchange in IOP or an IOP over 20 mmHg after 4weeks of therapy.

Conclusion:High dose topical steroids given for a period of atleast 1 month does not appear to increase IOP.

2:39PMEffects of Intranasal Budesonide Deliveredby Nasal Nebulizer on Symptoms andObjective Measures of Nasal Congestion inPerennial Allergic Rhinitis (PAR)Fuad Baroody, MD, James Lane, BSc,Marianella Paz-Silva, MD, Kristal Wimmer-Kunito, MD, Jayant Pinto, MD, Robert Naclerio, MDChicago, IL

Introduction: We hypothesized that intranasally nebulizedbudesonide would distribute better and be ofgreater benefit than an aqueous deliveredintranasal steroid. To investigate this hypothe-sis, we performed a pilot study investigatingnebulized budesonide vs placebo.

Methods: We performed a parallel, randomized, double-blind, placebo-controlled, pilot study in subjects(n=40) with PAR caused by dustmites or mold.After recording baseline symptoms, subjectswere randomized to budesonide respulses(0.25 mg), or an equivalent placebo for 26days. Nasal peak inspiratory flow (NPIF) andsymptoms (graded on a 0-3 scale) were record-ed by the subjects twice daily. Rhino-conjunc-tivitis quality of life (QOL) as well as nasal vol-ume, measured by acoustic rhinometry, wereobtained at baseline, after 2 weeks, and at theend of treatment.

Results:The total change from baseline in symptomswas greater for the group on budesonide (-86.5) compared to placebo (-51.5) (p=0.48).When the total change from baseline was com-pared between the groups, budesonide resultedin higher NPIF (945 l/min) than placebo (485l/min), p=0.099. QOL improved in both groupscompared to baseline with no significant differ-ence between the groups. On the final visit,nasal volume was higher in the group onbudesonide (16.9+/-0.9 cc) compared to place-bo (14.2+/-1 cc), p=0.055.

Conclusions: Compared to placebo, administration of nebu-lized budesonide in subjects with PAR resultedin improvements in symptoms and objectivemeasures of nasal congestion whichapproached but did not achieve statistical sig-nificance. A higher dose of active agent, and alarger number of subjects might have improvedstatistical significance.

2:46PM The Effect of Head Position on Distributionof Topical Medication using the MucosalAtomization Device on the ParanasalSinuses: A Cadaver StudyAl-Rahim Habib, BSc., Andrew Thamboo, MD,Rachelle Dar Santos, BSc, Jamil Manji, BSc,Eng Cern Gan, MD, Amin Javer, MDVancouver, BC

Objective: To determine the effect of head position,Lateral-Head-Back (LHB) versus Vertex-to-Floor (VTF), in the distribution of topical nasal


medication via Mucosal Atomization Device(MAD) in cadaver specimens.

Methods: Fourteen cadaver specimens received completefunctional endoscopic sinus dissection. The MADwas used to administer 1cc of fluoresceinimpregnated saline solution through the nose inboth the LHB and VTF position and visualized byblue light. Sites of distribution (inferior turbinate,anterior septum, middle turbinate, maxillarysinus, ethmoid sinus, frontal recess, frontalsinus, sphenoethmoid recess, sphenoid sinus,nasopharynx and olfactory cleft) were recordedwith endoscopic image capturing. Three rhinolo-gists were separately blinded to analyze theimages for the presence of staining.

Results: Fourteen cadaver specimens (n=28 nasal cavi-ties) received administration of the fluoresceinnasal spray in the LHB or VTF position. LHBposition had significant distribution of fluores-cein to all pertinent anatomical sites comparedto the VTF position (p=0.01; odds ratio [OR] =2.77; 95% confidence interval [CI] 2.16-3.57).Specifically, LHB had significantly greater distri-bution to the ethmoid sinus, frontal recess andfrontal sinus when compared to the VTF posi-tion (p<0.0001; odds ratio [OR], 3.92; 95% con-fidence intervals [CI] 2.17-7.10).

Conclusion: LHB position shows greater distribution to theethmoid sinus, frontal recess and frontal sinuswhen compared to VTF position. These areasare of particular clinical relevance to reducemucosal edema in patients with CRS.



3:25PMInvited Speaker: Andrew Goldberg, MDUpdate on the Etiology of CRS: Do ourSinuses Crave Certain Bacteria for Health?

Session: Rhinosinusitis: The Role ofBacteriaModerators: Pete Manes, MD, Erin O'Brien, MD

3:50PMImpact of Therapy on the CRS SinusMicrobiomeCindy Liu, MD, MPH, Katerina Soldanova, BS,Michael Dwan, BS, Lance Price, PhD., PaulKeim, PhD., Andrew Lane, MDBaltimore, MD

Introduction: Chronic rhinosinusitis is heterogeneous andtypically treated with maximum medical therapy.However, little is known about the impact ofmedical therapy on the sinus microbiota.

Methods:Adult patients with or without CRS, who havenot received antibiotics or corticosteroids in theprevious 8 weeks, were eligible. Three groupswere enrolled: Control (n = 40), CRSsNP (n =4), and CRSwNP (n = 2). A single maxillarysinus swab was collected from the controls, andpre- and post-therapy maxillary sinus swabswere collected from CRS participants. All werecollected under endoscopic guidance. RNA wasextracted from each swab to generate cDNA for16S rRNA gene-based pyrosequencing analy-sis. The pyrosequences were processed, taxo-nomically classified, and underwent compara-tive analyses.

Results:A total of 74,498 sequences were obtained.There was greater diversity (p < 0.05) and moreactive Corynebacterium spp. andPropionebacterium acnes in the sinus microbio-ta of controls than of untreated CRS patients (p< 0.05). In contrast, the untreated CRS micro-biota had more of various Staphylococcusspecies. After maximum medical therapy, thetreated CRS sinus microbiota showed frequent,minor gains in P. acnes and S. epidermidis andminor losses of S. aureus. But these changeswere accompanied by increases inPseudomonas spp. Microbiota diversityincreased significantly post-treatment (p < 0.05)to a level comparable to the controls.

Conclusion: Current maximum medical therapy can positive-ly affect the sinus microbiota, including increas-ing microbiota diversity. Yet, broad-spectrumantibiotics are limited in restoring microbiotacomposition and may shift the microbiotatowards resistant bacterial types.


3:57PMThe Impact of Culturable BacterialCommunity on Histopathology in CRSDarren Rom, MD, Kornkiat Snidvongs, PhD,Peta-Lee Sacks, MS, Ellie Pratt, BSc, Raymond Sacks, MDSydney, Australia

Background:The influence of the local microbial communityon inflammatory subtype in chronicRhinosinusitis (CRS) has been proposed bysome researchers. Mechanisms such as super-antigen suggest that Th-2/eosinophillic dominat-ed inflammation is a product of local flora andnot an intrinsic mucosal process. The associa-tions between cultured bacteria and thehistopathology and clinical features of patientswith CRS are described.

Methods:A cross-sectional study involving patients withCRS undergoing surgery was undertaken.Nasal swabs were performed at surgery formicrobiological evaluation. Mucosal biopsieswere taken and a histopathological profile wasperformed. Disease specific quality of life andnasal symptom scores were recorded. Thepresence of culturable organisms and particularpathogens were compared with histopathologyand clinical outcomes.

Results:95 patients were assessed (51.6% male, meanage 45.6+14.0 years), of which 47.3% had aculturable organism. High tissue eosinophilia(>10/HPF) was found in 34% of these patientsand 27% predominantly neutrophilic. No associ-ation between tissue eosinophilia and neu-trophilia was demonstrated for gram-positive orgram-negative organisms, Staphylococcusaureus or Pseudomonas species. A culturablepathogen predicted subepithelial fibrosis(x2=6.36, p=0.04) and gram-negative bacteriawere most strongly associated (x2=18.82,p<0.01). There were no other significant associ-ations with other clinical outcomes.

Conclusion:These findings suggest the culturable bacterialcommunity has little impact on histopathology inCRS. While there are more sensitive tests todetect bacteria in the sinuses, the impact of thesimple ‘culturable’ bacteria on the underlyingpathologic process is limited. Changes, such as

subepithelial fibrosis, suggests colonisation maylead to undesirable local mucosal damage.

4:04PMComparing Sinus and Pulmonary Cultures inPatients with Bronchiectasis and ChronicRhinosinusitsVijay Ramakrishnan, MD, Geoffrey Ferril, MD,Jeffrey Suh, MDAurora, CO

Introduction: Bronchiectasis is an uncommon disease of thelower airways characterized by bronchial walldestruction and permanent bronchiolar dilation.Several etiologic categories exist, and in gener-al, patients with bronchiectasis have anincreased incidence of chronic rhinosinusitis(CRS). The present study evaluates the corre-lation of bacterial culture results from the upperand lower airways in patients with bronchiecta-sis and CRS.

Methods: Retrospective chart review from a tertiary carerespiratory hospital was performed. The clinicaldatabase was searched by ICD-9 codes forpatients with bronchiectasis and CRS, andpatients with endoscopically-derived sinus cul-tures were included in the study. Demographicdata, history of prior endoscopic sinus surgery,and bronchiectasis etiology were obtained.Upper and lower airway cultures were com-pared using the chance adjusted agreement, orKappa statistic.

Results: Eighty-one patients were included in the study(age 17-88 years, mean 59; M:F ratio of 44-37).The most common etiologies of bronchiectasiswere idiopathic (26), mycobacterium (16), andimmunodeficiency (8). A statistically significantcorrelation of upper and lower airway bacterialcultures was found with respect to the five mostcommon bacteria identified (Kappa=0.323;p=0.014).

Conclusion: The current study supports the Unified AirwayTheory from a bacteriologic perspective, as cor-relation of upper and lower airway bacteriologywas seen with most bacteria identified. Thisfinding carries implications for disease patho-genesis, clinical care, and future research.



4:18PMPanel: Everyday Struggles in Our Practices-Expert Solutions!Moderator: Donald Lanza, MDPanelists: John DelGaudio, MD; Todd Kingdom,MD; Marc Dubin, MD; Stacey Gray, MD

5:00PMClosing Remarks and Adjournment Timothy L. Smith, MD, MPH President-elect and Program Chair

_____________________________________

COSM 2013Saturday SessionProgram DetailsSaturday, April 13, 2013JW Marriott Grande Lakes OrlandoMediterranean 5

8:00AMWelcome Timothy L. Smith, MD, MPH President-Elect and Program Chair

8:05AMPresidential Address Todd Kingdom, MD

Session: Surgical PracticesModerators: Greg Davis, MD, Zach Soler, MD

8:15AMOffice-Based Balloon Sinus Dilation: 52+week Follow-up of a Prospective MulticenterStudyAshley Sikand, MD, Stacey Silvers, MD, RazaPasha, MD, Alan Shikani, MD, Boris Karanfilov,MD, Michael Sillers, MDHenderson, NV

Introduction: Balloon Sinus Dilation (BSD) is an increasingly-used tool in Endoscopic Sinus Surgery (ESS),and emerging data demonstrates safety andefficacy when used in an office setting underlocal anesthesia.

Methods: Twenty-four week outcomes were previouslyreported for a large group of chronic rhinosi-nusitis patients refractory to medical manage-ment who underwent office-based transnasalBSD (Karanfilov et al, 2012). Peripheral sinus-es were dilated as medically appropriate, andoutcomes assessed by the validated SNOT20quality of life (QOL) instrument and revisionrates. Adverse events were collected tounearth any delayed safety concerns. We nowreport results for patients followed at least 52weeks.

Results:Of the original 203 patients enrolled, 122 werefollowed to their 52 week visit, with an averagefollow-up of 1.4 years (71.1 weeks). Therewere no baseline differences in SNOT20 orLund-McKay scoring between patients whowere followed to 52 weeks and those who werenot, although those followed to 52 weeks had asignificantly higher rate of prior sinus surgery.SNOT20 scores showed statistically significant(p<0.0001) and clinically meaningful (>0.8)change of -1.1 at 52+ weeks. Revision ratewas 7.4% (9/122). There were no device orprocedure-related adverse events between 24and 52+ weeks.

Conclusions:Performance of ESS with BSD in the officeunder local anesthesia has previously beenshown to be technically feasible, tolerable, andsafe. Results presented here demonstratedurable efficacy with clinically-meaningfulimprovement in symptoms and a low revisionrate in a cohort of over 100 patients with anaverage follow-up of 1.4 years.


8:22AMNovel Vacuum-Powered Mircodebrider forOffice Polypectomy: A Case SeriesAmin Javer, MD, Al-Rahim Habib, MD, EngCern Gan, MD, Iain Hathorn, MDVancouver, BC

Introduction: The waiting time for functional endoscopic sinussurgery (FESS) in patients with ChronicRhinosinusitis (CRS) refractory to medical treat-ment can be lengthy. Many such patients withnasal polyposis (NP) have significant nasalobstruction resulting in poor quality of life. Asimple and safe office-based polypectomydevice to de-bulk nasal polyps allows immedi-ate alleviation of nasal obstruction and betteraccess for topical medications.

Objective: To report the safety and efficacy of a novel vacu-um-powered microdebrider as a simple polypec-tomy device in the outpatient clinic setting.

Methods: Patients suffering from CRSwNP were selectedfor office polypectomy with a vacuum-poweredmicrodebrider between May 2012 andNovember 2012. These patients were eitherawaiting surgery, not keen for surgery, or hadrecurrent polyposis post surgery that wasamenable to office polypectomy. Pre and postNP grade and procedural questionnaires werecompleted pertinent to completeness, surgeonexperience and patient discomfort.

Results: Thirty-seven patients underwent office polypec-tomy in this case series. Thirty-three (89%) pro-cedures were successfully completed. Ofincomplete resections, 3 (8%) required tradi-tional electric-powered microdebrider resectionof remnant fibrous nasal polyps and 1 (3%) wasdue to a defective device. Twenty-eight (76%)cases presented with NP below the middlemeatus or with total obstruction. Twenty-seven(96%) were reduced to within the middle mea-tus. All patients reported acceptable discomfortduring use of the vacuum-powered microdebrid-er. There were no complications.

Conclusion: Our findings indicate that as a simple polypec-tomy device, this is a safe, effective, well-toler-ated and easy to use instrument to resect non-fibrous nasal polyps.

8:29 AMNasal Surgery for Obstructive Sleep Apnea-ARole for Endoscopic Sinus Surgery (ESS)?Rohan Wijewickrama, MD, Niranjan Sritharan,BSc., Rahul Gupta, MD, Ziad Rohayem, MD,Melinda David-Malesevich, MD, Peter Catalano, MDBoston, MA

Background: The curative impact of nasal surgery on patientsundergoing septal and turbinate surgery forobstructive sleep apnea (OSA) has been mini-mal. New models of nasal airflow mechanicshave shed important light on key functional ele-ments of nasal obstruction. Based on this infor-mation, we evaluated nasal surgery targetingareas of maximum nasal airflow as an appropri-ate treatment option for patients with OSA.

Methods:An IRB-approved study was performed includ-ing adult patients with diagnoses of both “chron-ic rhinosinusitis” and “obstructive sleep apnea”who underwent nasal and endoscopic sinussurgery by a single rhinologic surgeon duringan 18-month period. Nasal surgery included:uncinectomy, anterior/total ethmoidectomy, lat-eral excision of concha bullosa/hypertrophiedmiddle turbinate, septoplasty and inferiorturbinate reduction. The primary outcomemeasure was change in apnea-hypopnea index(AHI). Additional outcome measures includedchange in body mass index and oxygen-satura-tion (O2)-nadir.

Results:22 patients were identified with pre- and post-operative polysomnography results. Averagepreoperative AHI was 32.7 (Range 7.5 - 97.3)which was reduced by 19.3 to an average post-operative AHI of 13.4 (Range 3.3 – 47.5)(p=0.0002). However, O2-nadir and BMIremained relatively stable (? O2-nadir -1.1%;?BMI 0.3). No surgical complications occurredin this cohort.

Conclusions:Nasal surgery for OSA may be further opti-mized by concurrent targeted middle meatalsurgery aimed at increasing sinonasal airflow.Our surgical protocol is the first to demonstratesignificant reduction in AHI for OSA patientsregardless of severity.


8:36AMA Comparison of Septal Stapler to SutureClosure in Nasal Septoplasty: A Prospective,Randomized Trial Evaluating the Effect onOperative Time and OutcomesLeigh Sowerby, MD, Erin Wright, MDLondon, ON

Background: Septoplasty requires coaptation of the mucosalflaps; classically this was done with nasal pack-ing. Quilting sutures provide a welcome alter-native to packing, but can be time-consuming toplace. A septal stapler has recently been devel-oped that provides a rapid alternative to quiltingsutures but the time savings has not beenquantified.

Study Design: Prospective, randomized trial comparing a sep-tal stapler to quilting suture for coaptation ofmucosal flaps in septoplasty.

Method: After meeting inclusion criteria, patients under-went septoplasty and inferior turbinoplasty. Thetotal operative time, surgical segment times,and time for closure was recorded. Pre-opera-tive and post-operative NOSE scores wererecorded. A sample size of 16 was determinedto detect a difference of 5 minutes in closuretime.

Results: A total of 16 patients were enrolled in the study.The mean time for closure with septal staplerwas 35 +/-22 seconds versus 7 minutes +/- 1minute 10 seconds for suture closure(p<0.0001). The mean total operative timeusing the septal stapler was 28 minutes +/- 6minutes while 43 minutes +/- 13 minutes wasrequired for suture (p=0.014). No difference inpost-operative complications was seen or inpre- and post-operative NOSE scores.

Conclusions: Coaptation of the mucosal flaps in septoplastywith a septal stapler affords a time-savings inthe operating room with no difference in opera-tive outcome.


Session: Novel Research at the Cutting EdgeModerators: Vijay Ramakrishnan, MD,Ameet Singh, MD

8:50AMIdentification of Human Nasal MucosalEpithelial Stem CellsMrinmoy Sanyal, PhD, Justin Edward, MSEthan Soudry, MD, Dawn Bravo, PhDPeter Hwang, MD, Jayakar Nayak, MD, PhDStanford, CA USA

Introduction: New epithelial cells are generated through theproliferation and differentiation of resident stemcells in the adult nasal cavity. In several dis-eases, such as cystic fibrosis (CF) and chronicrhinosinusitis (CRS), we hypothesize that stemcells are likely functionally defective or fail toregenerate to maintain normal mucociliaryclearance. To better understand the etiopatho-genesis of these conditions, we attempted toreliably define and characterize human nasalepithelial stem cell populations.

Methods: Single cell suspensions of human ethmoidsinus tissue were prepared following endoscop-ic sinus surgery. Based on surface markersestablished for lung epithelial progenitor cells,we used a panel of antibodies (epithelial celladhesion molecules (EpCAM), CD45 (forhematopoietic cells), nerve growth factor recep-tor (NGFR/CD271), intercellular adhesion mole-cule-1 (ICAM-1/CD54) and integrin alpha 6(ITGA6/CD49f)) to identify epithelial progenitorcandidates by hi-dimensional flow cytometryand the gating technique of fluorescence minusone (FMO) controls. A lineage-negative popula-tion was purified to 100% homogeneity andanalyzed by immunofluorescence microscopyand air-liquid interface culture.

Results: A rare population of approximately 0.06% of totalethmoid cells was discriminated as EpCAM-CD45-, and NGFR+/ICAM-1+/ITGA6+ by surfacemarker expression. Immunofluorescencemicroscopy confirmed the purity and viability ofsorted cells, and upon in vitro culture, the clonalcell population spontaneously differentiated intoepithelial lineage cells.


Conclusion:Based on cellular coordinates of murine andhuman lung epithelial cells, we have identified apromising population of putative multipotentnative human nasal epithelial stem cells withinsinus tissues with the capacity to differentiateinto mucociliary cells of the normal nasalepithelium.

8:57AMDistribution of Human Nasal MesenchymalStem CellsBradley Goldstein, MD, PhD, Seth Lieberman,MD, Roy Casiano, MDMiami, FL USA

Introduction/Background:Olfactory neurons reside within the neuroepitheli-um of the human nasal mucosa.Neuroepithelium is restricted to the superiorregions, lining portions of the septum and superi-or turbinates in general. Olfactory epithelium is aself-renewing tissue, producing new neuronsfrom stem and progenitor cells in its basal layers.In addition, there exists a mesenchymal-likestem cell (MSC) located within the underlyinglamina propria. Little is known about the functionof this nasal MSC, or its relationship to the olfac-tory lineage, but there is considerable interest inutilizing the nasal MSC for cell-based therapies.We sought to further explore the biology of thenasal MSC by establishing neurosphere culturesfrom adult human nasal biopsies.

Methods:Adult patients undergoing endoscopic surgeryfor treatment of sinonasal or skull base disor-ders were consented for the use of nasal tissuesamples for research. We established culturesfrom superior, middle and inferior turbinates.Cells grown as neurospheres were analyzedimmunochemically and via flow cytometry.

Results:Nasal MSC cultures were obtained from olfacto-ry as well as non-olfactory regions, from all 3turbinates. These MSC cultures exhibit charac-teristic robust neurosphere formation andexpress CD90, CD105, STRO-1 and nestin.

Conclusions:The unexpected anatomic distribution of nasalMSCs suggests a broad role for this cell, andfurther experiments are underway to define

MSC function. Given the rapid pace in effortsaimed at the development of cell-based thera-pies, these findings have important implicationsfor efforts aimed at utilizing nasal MSCs thera-peutically.

9:04AMConstitutive Expression of VEGF GeneFamily Ligand and Receptors on HumanUpper and Lower Airway Epithelial CellsJean Kim, Md, PhD, Hyun Lee, Ph.D,Baltimore, MD

Introduction: We previously reported that VEGF-A is abun-dantly expressed by primary human nasalepithelial cells (PNEC) and functions to promotecell hyperplasia in chronic rhinosinusitis withnasal polyposis (CRSwNP). Therefore weaimed to examine the full expression profile ofother members of the VEGF gene family of lig-ands and receptors that may potentially play arole in the development of CRSwNP.

Methods: mRNA and protein expression of VEGF genes,receptors, and co-receptors was examined fromcultured PNEC and compared to that from pri-mary human bronchial epithelial cells (PBEC)and BEAS2B cell line by realtime PCR and flowcytometry.

Results: We report abundant expression of VEGF-A,VEGF-B, and VEGF-C, detected by mRNA andflow cytometric analysis on PNEC. We hereinreport that there is significant expression ofVEGFR3 and both neuropilin co-receptors, NP1and NP2, but no detectable VEGFR1 orVEGFR2 at baseline conditions on PNEC.Lower airway PBEC and BEAS2B cells dis-played similar patterns of expression.Conclusions: PNEC express high constitutive levels of VEGFgene family homolog of ligands and receptors.Expression of multiple VEGF ligand-receptorcombinations may function as redundant path-ways to promote upper and lower airway epithe-lial cell growth during airway inflammation.


9:11AM Anti-inflammatory Mediators and SleepDysfunction in Chronic RhinosinusitisJeremiah Alt, MD, PhD, Nathan Sautter, MD,Kara Detwiller, MD, Dennis Trune, MD, MBA,Jess Mace, MPH, Timothy Smith, MD, MPHPortland, OR

Introduction: The pathophysiology of sleep disturbance inpatients with chronic rhinosinusitis (CRS) is poor-ly understood. Pro-inflammatory cytokines areinvolved in physiological sleep regulation. It ishypothesized that anti-inflammatory cytokinesinhibit non-rapid eye movement sleep (NREMS)through inhibition of somnifacient pro-inflamma-tory mediators. We therefore, evaluated theexpression of anti-inflammatory mediators knownto inhibit NREMS sleep in patients with CRS.

Methods: A total of 20 patients diagnosed with medicallyrefractory CRS were prospectively enrolled andcompleted the Pittsburgh Sleep Quality Index(PSQI) survey. Ethmoid mucosa samples wereobtained during endoscopic sinus surgery andquantitative real-time polymerase chain reactionwas performed for interleukin (IL) -4, -13, andtransforming growth factor beta (TGF-ß). Theaverage change in crossover threshold was cal-culated and differences in target gene expres-sion were correlated to both PSQI total andsub-domain scores using unadjustedSpearman’s correlation coefficients.

Results:Eighteen (90%) of study subjects with CRSreported poor quality of sleep as measured bythe PSQI. Increased expression of TGF-ß sig-nificantly correlated with poor PSQI sleep dura-tion scores (r= -0.443; p=0.050), while elevatedlevels of IL-4 expression were associated withworse sleep disturbance (r= -0.548; p=0.012).Increased expression of IL-13 also correlatedwith worse total PSQI scores (r= -0.417;p=0.075).

Conclusions: Patients with CRS generally have poor sleepquality as measured by the PSQI instrument.The up-regulation of anti-inflammatory media-tors in CRS may be, in part, associated with theinflammation-brain regulated effects on sleepquality.


9:25AMPanel: Inferior Turbinate Reduction Surgery:Minimalist vs. TurbinatorModerator: Pete Batra, MDPresenters: Roy Casiano, MD, Martin Citardi, MD

9:55AMBreak with Industry Partners

Session: Disease Manifestations andTreatment OutcomesModerators: Ayesha Khalid, MD,Abtin Tabaee, MD

10:25AMA Systematic Review and Meta-analysis ofAsthma Outcomes Following EndoscopicSinus Surgery for Chronic RhinosinusitisRishi Vashishta, MD, Rodney Schlosser, MDZachary Soler, MD, MScCharleston, SC USA

Background:A clinical question which commonly arises iswhether endoscopic sinus surgery for chronicrhinosinusitis can improve asthma-specific out-comes in patients suffering from both condi-tions. This study presents a systematic reviewand meta-analysis to assess the effects ofendoscopic sinus surgery on asthma outcomes.

Data Sources:Ovid MEDLINE and the Cochrane databases.

Methods:The above sources were searched to identifystudies examining asthma outcomes in patientswith chronic rhinosinusitis following endoscopicsinus surgery. Included studies involved acohort of at least 5 patients and reported atleast one postoperative asthma outcome follow-ing sinus surgery.

Results:Twenty-one studies involving 812 patients wereincluded in the analysis. Mean (SD) follow upwas 26.7 (30.3) months postoperatively.Patients reported improved overall asthma con-trol in 77.7% (95% CI, 72.4% to 82.3%) ofcases. The frequency of asthma attacksdecreased in 85.1% (95% CI, 75.1% to 91.7%)


of patients and the number of hospitalizationsdecreased in 64.8% (95% CI, 53.2% to 74.9%).Decreased use of oral corticosteroid was seenin 72.9% (95% CI, 67.3% to 77.8%) of patients;inhaled corticosteroid use decreased in 28.6%(95% CI, 23.1% to 35.0%) and bronchodilatoruse decreased in 36.4% (95% CI, 29.4% to44.1%) of patients. Mean (SD) improvement inpercent predicted FEV1 was 1.62%, but wasnot statistically significant.

Conclusions:Endoscopic sinus surgery in patients with con-comitant bronchial asthma appears to improvesome but not all asthma outcome measures. Alack of controlled clinical trials limits thestrength of conclusions which can be reached.

10:32AMSurgical Management of ChronicRhinosinusitis in Cystic Fibrosis: ASystematic ReviewJonathan Liang, MD, Thomas Higgins, MD,MSPH, Stacey Ishman, MPH, Emily Boss, MD,MPH, James Benke, BS, Sandra Lin, MDBaltimore, MD

Objective: To systematically review literature on the effec-tiveness of surgical management for chronicrhinosinusitis in cystic fibrosis (CF) patients.

Methods: We performed a literature search encompassingthe last 25 years in PubMed, Embase, andCochrane CENTRAL. Inclusion criteria includedEnglish language papers containing originaldata, more than 6 subjects, and measurable clin-ical outcomes. Data was systematically collectedon study design, patient demographics, clinicalcharacteristics and outcomes, and level-of-evi-dence. Two investigators independently reviewedall manuscripts. A quality assessment of includ-ed studies was performed to assess bias.

Findings: The initial search yielded 415 abstracts, ofwhich 21 articles were included, detailing 561adult and pediatric CF patients who underwentsurgical therapy. Surgical treatment in all stud-ies included endoscopic sinus surgery.Outcome measures included sinonasal symp-toms (12/21), endoscopic findings (6/21), pul-

monary function testing (6/21), recurrence orrevision surgery (4/21), hospitalization (3/21),need for antibiotic therapy (1/21), pulmonaryexacerbations (1/21), and radiographic findings(1/21). The level-of-evidence was predominant-ly level 4 (16/21); there were no level 1 evi-dence studies. Most studies found improvementin symptom measures and endoscopic findingsbut no improvement in lower airway functionafter surgical therapy. Post-operative measuresof the other outcomes were inconclusive orinconsistent.

Conclusions: Endoscopic sinus surgery for adult and pedi-atric CF sinusitis yielded clinical improvementprimarily in patient sinonasal symptoms andendoscopic findings. It is unclear whether sur-gical intervention modifies lower airway dis-ease. Future prospective studies with predeter-mined, objective, and validated outcome meas-ures are needed to determine the effictivenessof surgical intervention for CF-related chronicrhinosinusitis.

10:39AMOstiomeatal Occlusion Does Not Correlatewith Sinus Disease in EosinophilicRhinosinusitis* Dr Kornkiat Snidvongs*(PJ Wormald Research Award from AustralasianRhinologic Society)

Objective: Ostiomeatal complex (OMC) occlusion mayplay a role in the pathogenesis of some chronicrhinosinusitis (CRS) subgroups but its role indiffuse mucosal inflammation is strongly debat-ed. The association between radiological OMCocclusion and its draining sinuses in patientswith eosinophilic rhinosinusitis (ECRS) com-pared to non ECRS is investigated.

Methods: Patients with CRS who underwent endoscopicsinus surgery were investigated. Pre-operativecomputed tomography scans were evaluated.Structured histopathology reporting was per-formed. The study group was patients with hightissue eosinophil >10/high power fields (HPF)and the control group were patients with low tis-sue eosinophil ?10/HPF. The radiological rela-tionship of OMC occlusion to the draining sinus-es was analyzed in each group.


Results: Seventy patients with a mean age of 49.7 ±14.1years were analyzed. Fort-one (48.7%)patients had high tissue eosinophil >10/ HPF.All patients with ECRS had maxillary diseaseand there were 36.2% without OMC occlusion.There was no association of OMC occlusion tothe either anterior ethmoid (ECRS; OR=1.84(0.24, 14.14), p=0.55, non ECRS; OR=1.57(0.34, 7.33), p=0.56) or frontal sinuses (ECRS;OR=0.67 (0.12, 3.82), p=0.65, non ECRS;OR=1.58 (0.45, 5.54), p=0.47) . For patientswith non-ECRS, maxillary sinus diseases waspresent in 96.2% of those with OMC occlusionand 50% of those without (odd ratio (OR) =25.0(2.77, 226.08); p<0.001).

Conclusion: OMC occlusion is not associated with drainingsinuses for patients with ECRS. Simple surgicalinterventions directed at the OMC are unlikelyto be of benefit to this CRS subgroup.


Session: Treatment Outcomes and CostEffectivenessModerators: Jean Anderson Eloy, MD, Jamie Litvack, MD

10:53AMImpact of Continued Medical Therapy inPatients with Refractory ChronicRhinosinusitisKristine Smith, MD, Luke Rudmik, MDCalgary, Alberta Canada

Background:Prolonged surgical wait-times in Canada offers aunique opportunity to study the impact of ongo-ing medical therapy in patients with refractorychronic rhinosinusitis (CRS) who are candidatesfor endoscopic sinus surgery (ESS). The primaryobjective of this study was to evaluate thechange in disease-specific quality of life (QoL) inpatients with refractory CRS who received ongo-ing medical therapy pending ESS.

Methods:A total of 18 patients were prospectivelyenrolled between November 2011 andNovember 2012. Inclusion criteria: > 18 years,CRS defined by AAO adult sinusitis guidelines,

failed initial medical therapy (defined by a mini-mum of 3 months of topical intranasal steroid, 7day course of systemic steroid, +/- 2 weekcourse of broad spectrum systemic antibiotic),and elected ESS. The primary outcome waschange in disease-specific QoL (SNOT-22)between time of enrollment and immediatelyprior to ESS. Secondary outcomes included:medication usage, physician visits, and workdays missed.

Results:At the time of enrollment, the mean SNOT-22(SD) score was 58.8 (19.5). Following contin-ued medical therapy for a mean of 5.7 months,the mean SNOT-22 score increased to 63.4(22.3). This difference was not statistically sig-nificant (p=0.509).

Conclusions:Data from this study suggests that patients withrefractory CRS receive no improvement in dis-ease-specific QoL from ongoing medical thera-py while awaiting ESS. This highlights theimportance of ESS in the management ofrefractory CRS.

11:00AMImpact of Symptom-based Risk Stratificationon the Cost Effective Diagnosis of Patientswith Chronic Rhinosinusitis SymptomsBruce Tan, MD, Guanning, Lu, BS, RandyLeung, MD, Rakesh Chandra, MD, DavidConley, MD, Robert Kern, MDChicago, IL

Background:Current symptom criteria poorly predict a chron-ic rhinosinusitis (CRS) diagnosis resulting incost inefficient treatment of symptomaticpatients.

Objective: To analyze the positive predictive value (PPV)of symptoms and examine the cost effective-ness of the subsequent treatment algorithmusing a Markov economic model.

Methods: We calculated the PPV of individual symptomspreviously collected from a cross-sectionalstudy of 80 patients presenting to an otolaryn-gology clinic with CRS symptoms. Classificationand regression tree (CART) analysis optimized


the sequence of symptoms to risk stratify CRSpatients. Calculated PPV were applied to aMarkov economic model comparing an upfrontCT (uCT) algorithm against an empiric medicaltherapy (EMT) algorithm depending on theavailability of point of care (POC) imaging.

Results:The PPV of individual symptoms ranged from0.39 to 0.69 for patients reporting facial painand hyposmia respectively. CART modellingconstructed a dichotomous tree based on fore-head pain, maxillary pain, hyposmia, nasal dis-charge, and facial pain (C-statistic 0.83). WhenPOC CT is available, median costs ($64-$319)favor uCT for all individual symptoms. If POCCT is unavailable, median costs favor uCT formost symptoms except hyposmia (-$100) anddiscolored nasal discharge (-$24) but all symp-toms were equivocal on cost sensitivity analy-sis. The three-tiered CART model subcatego-rized patients into tiers where uCT was favored(median costs: $332-$504) and others whereEMT was always favored (median costs -$121to -$275).

Conclusion: Individual symptoms, or symptoms in combina-tion, varied the likelihood of a CRS diagnosisand impacts the cost effectiveness of subse-quent medical care.

11:07AMComparison of Outcomes of EndoscopicLigation and Endovascular Treatment ofSphenopalatine Artery for Epistaxis: a five-year Series from a Single InstitutionNirav Thakkar, MD, Joseph Raviv, MDChicago, IL

Introduction: Approximately 90% of patients with epistaxisare treated effectively with an anterior nasalpacking and outpatient follow-up. Conventionaltreatment for those that fail anterior packing is aposterior packing with inpatient monitoring for3-5 days. Transnasal endoscopic sphenopala-tine artery ligation (ESAL) and endovascularembolization are options typically reserved forcases in which packing has failed. The objec-tive of this study is to evaluate the safety andefficacy of ESAL and intravascular embolizationfor the treatment of severe epistaxis.

Methods: This study is a retrospective review of all ESALand embolization procedures from 2007 to 2012at our institution. A comparison of safety andefficacy of each procedure was performedalong with a literature review on ESAL,embolization, and the cost effectiveness ofeach procedure.

Results: Over 5 years, 33 patients were treated withESAL and 11 were embolized with success rate94% and 82% respectively. There was onepost-operative complication for ESAL patients,which was sinusitis that resolved with antibiotictreatment. Of the patients treated withembolization, 1 patient died and 1 patient hadsevere facial pain requiring prolonged narcoticpain control.

Conclusion: This is the largest series reported in the US ofESAL patients and the only review that com-pares them to embolization. Surgical interven-tion by ESAL for the treatment of severe epis-taxis was safer and more effective thanembolization. Given the safety, efficacy, andcost effectiveness of early intervention, oto-laryngologists should strongly consider ESALas primary treatment for severe epistaxis.


11:19AMPanel: The Cutting Edge: From Lab Benchto Bedside-Improving Care for Our Patients

Moderator: Ralph Metson, MDPanelists: Bruce Tan, MD; Sarah Wise, MD;Brad Woodworth, MD

12:00PMLunch Break with Industry Partners


Session: Steroids in Chronic RhinosinusitisModerators: Steve Pletcher, MD, Nathan Sautter, MD

1:00PMThe Effect of Intranasal FluticasonePropionate Irrigations on Salivary Cortisol,Intraocular Pressure, and PosteriorSubcapsular Cataracts in PostsurgicalChronic Rhinosinusitis PatientsLi-Xing Man, MSc, MD, MPA, Zachary Farhood,BA, Robert Feldman, MD, Philip Orlander, MDAmber Luong, MD, PhD, Samer Fakhri, MDMartin Citardi, MDRochester, NY USA

Introduction: Intranasal corticosteroid irrigations, especiallybudesonide, are used increasingly in the man-agement of chronic rhinosinusitis. In post-endo-scopic sinus surgery patients, irrigations mayoffer improved delivery at higher doses to theparanasal sinuses than intranasal spray prepa-rations. Fluticasone propionate may have high-er potency and lower systemic bioavailabilitythan budesonide, but there is little data on itseffects as an intranasal irrigation on the adrenalaxis or on ocular findings.

Methods: Adult patients who had previously undergonebilateral endoscopic sinus surgery and had nottaken systemic corticosteroids in the last 6months were prospectively enrolled. Subjectsirrigated with 3 mg of fluticasone propionate in240 mL saline solution twice daily. Salivary cor-tisol, intraocular pressure, and the presence ofposterior subcapsular cataracts were measuredbefore drug administration and after 6 weeks ofcontinuous use.

Results: Twenty-two subjects completed the study. Nosubjects had salivary cortisol levels below thenormal range before or after therapy, and therewas no statistical difference in mean salivarycortisol levels pre- and post-treatment (0.301vs. 0.399 µg/dL; p=0.30). There was no clinicalor statistical difference in mean intraocularpressure before or after therapy (13.5 vs. 13.5mm Hg; p=0.86). No subjects developed a pos-terior subcapsular cataract.

Conclusion: Fluticasone propionate irrigations did not sup-press salivary cortisol levels or result in ocularchanges. Irrigation with fluticasone propionate 3mg in 240 mL saline twice daily may be a safealternative to other intranasal or systemic corti-costeroid treatments for chronic rhinosinusitispatients.

1:07PMWhen do the Risks of Repeated Courses ofCorticosteroids Exceed the Risks ofSurgery?Randy Leung, MD, Keith Dinnie, Timothy Smith, MD, MPHBarrie, ON

Introduction: When patients with chronic rhinosinusitis withnasal polyposis require repeated courses ofsystemic corticosteroids to maintain quality oflife, the relative risk of repeated steroid coursesversus surgery is unclear. This study aims toidentify the threshold when the risks of repeat-ed courses of corticosteroid exceed the risks ofsurgery.

Methods: An evidence-based risk analysis was simulatedusing literature reported complication rates,quality of life changes, and Medicare costs.

Results: Risk simulations demonstrated a base caseestimate of a five-fold risk associated with sur-gery over a single course of prednisone.

Conclusions: This represents the first rationalized evidence-based assessment of risk for repeated systemicsteroids versus surgery. This threshold providesa tool to clinicians for evidence-based decisionmaking in complex situations.


1:14PMSystemic Prednisone AdministrationSelectively Alters Granulocyte Subsets inNasal Polyps from AERD and CRS PatientsJustin Edward, MS, Mrinmoy Sanyal, PhD,Vijay Ramakrishnan, MD, Peter Hwang, MD,Todd Kingdom, MD, Jayakar Nayaki, MD, PhDStanford, CA

Introduction: Nasal polyps (NP) are classically associatedwith abundant eosinophils; however, other gran-ulocytes such as neutrophils and basophils arealso present and clinically significant. Thoughsystemic steroids transiently reduce the cellularburden of NP, the mechanism for this changeremains unclear. Therefore, we sought to deter-mine the effects of prednisone treatment ongranulocyte subsets in patients with chronic rhi-nosinusitis with nasal polyps (CRSwNP) and inthe subset with aspirin exacerbated respiratorydisease (AERD).

Methods: NP, adjacent ethmoid sinus tissue, and periph-eral blood mononuclear cells (PBMCs) wereobtained from patients undergoing endoscopicsinus surgery. Fresh samples from five cohorts:CRSwNP±prednisone (n=6 each), AERD±pred-nisone (n=6 each), and controls (n=9), wereanalyzed by hi-dimensional flow cytometry togate and quantify all granulocyte populations.Some specimens were archived for confocalimmunofluorescence microscopy.

Results: Eosinophils are significantly reduced (p=0.0004,n=6) in NP in both AERD and CRSwNP afterpreoperative treatment with oral prednisone. Asignificant decrease in neutrophils (p<0.05,n=6) is also seen in NP after prednisone treat-ment in CRSwNP, but not in AERD. In contrast,steroids do not significantly change the percent-age of basophils (p=0.48, n=6) within NP fromeither group. Interestingly, granulocyte subsetsin both the adjacent ethmoid sinus mucosa andPBMCs are unaffected by steroid treatment.Confocal microscopy further validated thesefindings.

Conclusions:Eosinophil and neutrophil counts are focallyaffected within NP tissue by systemic steroidexposure, without notable granulocyte alter-ations in the surrounding regional tissues.

These data provide direct insights into the cellu-lar effects of prednisone exposure in patientswith CRSwNP.

1:21PMChronic Rhinosinusitis with Nasal Polyps isAssociated with Increased Nrf2 MediatedAntioxidant Gene ExpressionMurugappan Ramanathan, MD, Gina Paris, BS,Michelle Mendiola, BS, Shyam Biswal, PhD,Andrew Lane, MDBaltimore, MD

Background: Chronic Rhinosinusitis with Nasal Polyps(CRSwNP) is an uncontrolled inflammatory con-dition and its pathogenesis remains unclear.Recent studies suggest that environmentalexposures may contribute towards sustainedsinonasal inflammation. Nrf2 is a redox-sensi-tive transcription factor that upregulates a bat-tery of antioxidative genes and cytoprotectiveenzymes that constitute the cellular response toenvironmental exposures and oxidative stress.The role of Nrf2 and its associated anti-oxidantgenes in CRS has never previously beenexplored.

Methods: Sinonasal mucosal biopsies from the ethmoidcavity were taken from CRSwNP patients dur-ing routine endoscopic sinus surgery. Similartissue was also acquired from non-diseasedcontrol patients during orbital or skull base sur-gery. mRNA was extracted from samples andreal-time PCR was performed for the followingNrf2 mediated antioxidant genes: HO-1, GCLC,GCLM, and NQ01.

Results: mRNA for all the Nrf2 regulated anti-oxidantgenes was detected in both CRSwNP and con-trol patients. However, CRSwNP patients hadstatistically significant increases in mRNAexpression of Nrf2 mediated antioxidants whencompared to controls.

Conclusions: Elevated levels of Nrf2 mediated anti-oxidantsin CRSwNP likely represents the body’s cellulardefense against increased oxidative stress.Although Nrf2 levels and associated anti-oxi-dants are increased in CRSwNP compared tocontrols, these levels may be insufficient to


detoxify the oxidative stress burden. Furtherstudies are needed to determine the potential ofNrf2 mediated anti-oxidants as a therapeutictarget in CRSwNP.


Session: Management of CSF Leaks andOlfactionModerators: Nithin Adappa, MD, Jonathon Liang, MD

1:35PMAcetazolamide for High IntracranialPressure CSF LeaksMohamad Chaaban, MDAjaz Chaudhry, MD, Elissa Illing, MDKristen Riley, MD, Bradford Woodworth, MDLaGrange, GA USA

Objectives/Hypothesis: Acetazolamide has become a standard treat-ment for CSF leaks associated with intracranialhypertension. The purpose of the current studywas to evaluate the effectiveness of acetazo-lamide at decreasing elevated CSF pressure inthis patient population.

Methods: Prospective evaluation and data collection ofhigh intracranial pressure CSF leaks was per-formed. Subjects underwent CSF diversion andpostoperative assessment of pressure changesvia a standard protocol. Lumbar drains or ven-triculostomies were clamped on postoperativeday 2 for 4 hours prior to assessment with amanometer. Acetazolamide (500 mg) wasadministered orally immediately following therecording and CSF pressure measured after 4hours. Data regarding demographics, etiologyof CSF leak, body mass index (BMI), locationand size of defect, and clinical follow up werealso collected.

Results: Thirty-two patients (avg. age 50) with 36 CSFleaks (33 spontaneous, 3 traumatic) and anaverage BMI of 35.1 were evaluated. Successrate of primary repair was 94.4%, but allpatients were effectively sealed with subse-quent endoscopic reconstruction (avg. 80

weeks follow up). Intracranial pressure (cmH2O) via lumbar puncture or ventriculostomy(n=2) after clamping was 31.3+/-7.3.Administration of acetazolamide significantlydecreased intracranial pressure to 21.4+/-7.4 inthe 4 hour time frame studied (p<0.0001).

Conclusion: This study provides some of the first direct evi-dence of decreased intracranial pressure asso-ciated with the oral administration of acetazo-lamide. In combination with the excellent endo-scopic repair outcomes noted in a high riskpopulation, this evidence supports the routineuse of acetazolamide in patients with highintracranial pressure CSF leak.

1:42PMPorcine Small Intestine Submucosal Graftfor Endoscopic Skull Base ReconstructionElisa Illing, MD, Mohamad Chaaban, MD,Kristen Riley, MD, Bradford Woodworth, MDBirmingham, AL

Objectives/Hypothesis: Skull base defects and encephaloceles of thesinus and nasal cavities are routinely repairedendoscopically with high success rates using avariety of materials including bone, cartilage,fascia, acellular dermal allografts, andxenografts. However, there is a paucity of dataregarding the use of porcine small intestinesubmucosal (SIS) grafts for endoscopic duralrepair. The purpose of the current study wasto review outcomes using SIS grafts in theendoscopic reconstruction of skull base defects.

Methods: Review of prospectively collected data regard-ing skull base defect repair using SIS was per-formed. Demographics, location and size ofskull base defect, method of repair, successfulclosure, and complications were recorded.

Results: Over 4 years, 146 patients (avg. age 46) under-went 161 primary skull base repairs utilizingporcine SIS. Etiologies included tumor (75),spontaneous (47), trauma (34), and congenital(5). The majority of repairs were in combinationwith a nasoseptal flap (n=113). Average defectsize (length vs. width) was 13.3x10.7mm.Success rate on first attempt was 94.4%(152/161), but all defects were effectively


sealed on subsequent endoscopic revision.The average follow up was 77 weeks. Therewas an 8.1% incidence of major postoperativecomplications [recurrent CSF leak (9), meningi-tis (2), periorbital cellulitis (1), and invasive fun-gal sinusitis (1)] that resulted in no residual longterm sequelae.

Conclusion: Dural repair utilizing porcine SIS graft wasassociated with excellent outcomes in the cur-rent study and supports its routine use in theendoscopic closure of skull base defects.

1:49PMInterferon Gamma Causes OlfactoryDysfunction Without ConcomitantNeuroepithelial DamageAndrew Lane, MD, Tatyana Pozharskaya, MS Baltimore, MD

Introduction:Olfactory loss is a debilitating symptom ofchronic rhinosinusitis (CRS). The pathophysiol-ogy of inflammatory olfactory dysfunction likelyinvolves both conductive and sensorineuralcomponents. To study the interaction of CRS-associated inflammatory cytokines with theolfactory epithelium, a transgenic mouse modelwas developed that allows temporally-controlledlocal gene expression. Interferon-gamma(IFNG) is a prototypical Th1 cytokine linked tonon-polypoid CRS, as well as sinonasal viraland bacterial infections. In this study, the effectsof chronic IFNG expression on olfactory histol-ogy and function were investigated.

Methods:IFNG secretion by olfactory sustentacular cellswas induced in the transgenic mouse. Viabilityand gross behavior were unaffected. Micewere sacrificed after 6 weeks of IFNG expres-sion, and olfactory tissue was studied by histol-ogy, immunohistochemistry, and electro-olfac-togram (EOG). Findings were compared withuninduced littermates.

Results:IFNG expression did not result in alteration ofthe normal histologic architecture of the neu-roepithelium or lamina propria. However, EOGrecordings demonstrated a significant decreasein odorant responses after IFNG expression. Inaddition, a marked increase in submucosal

CD45-positive cells was observed, the majorityof which were CD3 and CD4 positive lympho-cytes.

Conclusion:Chronic IFNG expression in the mouse olfacto-ry epithelium results in diminished odorantresponsiveness, despite the absence of inflam-matory tissue damage. This suggests a directeffect of IFNG on olfactory neuron function thatmay underlie olfactory loss in CRSsNP or viralinfections. The infiltration of submucosal lym-phocytes raises the possibility that other down-stream cytokines also contribute to olfactorydysfunction.


2:03PMPanel: Evidence-Based Rhinology: How hasthe Evidence Changed my Treatment ofSinonasal Disease?

Moderator: Michael G. Stewart, MD, MPHPanelists: Jack Krouse, MD; Brent Senior, MD;David Poetker, MD; Stephanie Joe, MD


Session: Sinonasal and Skull Base TumorsModerators: Troy Woodard, MD , Adam Zanation, MD

3:25PMEvolution in the treatment of sinonasalinverted papilloma: the Pedicle OrientedEndoscopic Surgery (POES)Alessandro Pusateri, MD, Georgios Giourgos,MD, Elina Matti, MD, Francesco Chu, MDMichele Caputo, MD, Fabio Pagella, MD

Introduction: The global efficacy of the endoscopic treatmentin sinonasal inverted papilloma (IP) is known,and reaches a 95%. The objective of this studyin to evaluate an even more conservative endo-scopic approach, based on the research of thetumor’s pedicle and the aggressive treatmentconcentrated on its site of attachment.


Methods: Retrospective analysis of the patients treated inour institution for sinonasal IP, between 2002and 2011 and a minimum of 12 months of fol-low-up. Group A received a standard endoscop-ic sinus surgery including whole sinus’ demuco-sization, bony wall drilling and endoscopicmedial maxillectomy in case of maxillary local-ization. Group B patients’ instead, underwentthe Pedicle Oriented Endoscopic Surgery(POES), in this group, bony demucosizationand drilling were selectively conducted aroundthe site of pedicle’s attachment of the tumor.

Results: The cohort included 73 patients (49 males, 24females), mean age 59 years (25 – 83 years),mean follow-up 63 months (12 – 138 months).Group A/Group B: 37/36 patients. IP persist-ence-recurrence: Group A/Group B: 0/1 cases.Oncological success: Global endoscopic/GroupA/Group B: 98.6% (72/73) / 100% (37/37) /97.2% (35/36). No major intra- and post-opera-tive complications were observed.

Conclusions: Our data confirm the efficacy of the endonasalendoscopic treatment for sinonasal IP.Moreover, the even more conservative endo-scopic treatment proposed (POES) seems tooffer good control of the disease, shorter oper-ating time, avoidance of unnecessary surgerywith respect of not involved structures and per-mits a follow-up aimed at the site of pedicle’sattachment.

3:32PMp16, EGFR, CyclinD1, and p53 StainingPatterns for Inverted PapillomaGiant Lin,MD, Mark Zacharek, MD, Jonathan McHugh, MD, Thomas Carey, PhDAnn Arbor, MI

Introduction:We aim to better characterize the staining pat-terns of inverted papilloma (IP) with and withoutcarcinoma by performing immunohistochemistrywith p16, EGFR, p53, and Cyclin D1 antibodieson a large patient cohort.

Methods:We identified 162 IP specimens from 122patients treated at the University of Michiganbetween 1996 and 2011. 22 specimens con-

tained carcinoma. Tumor was extracted for con-struction of two tissue microarrays and stainedfor p16, EGFR, p53, and Cyclin D1. Tumorstaining intensity and percentage staining werescored by an experienced head and neckpathologist.

Results:For IP and IP with carcinoma, p16 stained in100/133 (75%) versus 4/21 (19%) specimens(p<0.001), EGFR in 71/135 (53%) versus 15/21(71%) specimens (NS), p53 in 65/135 (48%) ver-sus 16/21 (76%) specimens (p<0.05), Cyclin D1in 110/136 (81%) versus 16/21 (76%) specimens(NS). Mean percentage staining for IP and IPwith carcinoma was 12% versus 7% for p16(p<0.001), 20% versus 34% for EGFR (NS), 4%versus 24% for p53 (p<0.001), and 17% versus21% for Cyclin D1 (NS). Applying criteria for pos-itive staining as >10%, specimens with carcino-ma were positive for p16 in 14%, EGFR in 68%,p53 in 50%, and CyclinD1 in 45%. Benign IPwas positive for p16 in 35%, EGFR in 43%, p53in 14%, and CyclinD1 in 51%.

Conclusion:EGFR and Cyclin D1 staining is heterogeneousand not significantly different between IP and IPwith carcinoma. Low affinity to p16 and highlevels of p53 may serve as markers for malig-nancy in this disease.

3:39PMQuality of Life Metrics after Surgery forSinonasal Neoplasms: Analysis ofPredictive FactorsNathan Deckard, MD, Brian Harrow, MSII, BS,Samuel Barnett, MD, Pete Batra, MDDallas, TX

Introduction: Endoscopic resection of sinonasal and skullbase neoplasms has been an importantadvance in the field of skull base surgery.However, there is a relative paucity of literatureassessing the quality of life (QOL) of patientsundergoing endoscopic tumor surgery.

Methods: Prospective QOL data was collected using theSino-Nasal Outcome Test (SNOT-20), Lund-Kennedy Endoscopic Score (LKE), AnteriorSkull Base Questionnaire (ASBQ), andEuropean QOL questionnaire (EQ5) in 71


patients with sinonasal and skull base tumorsmanaged between January 2009 and August2012. Statistical analysis was performed toidentify predictive factors affecting QOL.

Results: The mean age was 53 years and mean follow-up was 14.5 months at the time QOL data wascollected. Benign and malignant tumors repre-sented 39 (54.9%) and 32 (45.1%) cases,respectively. Twenty malignancies (62.5%)were stage T3 or T4, while 23 required postop-erative chemotherapy and radiation (CRT).Factors predicting worsened postop QOLincluded malignant histopathology, T3 or T4tumors, and the use of postop CRT (p<0.05).The presence of an intraoperative CSF leakwas only statistically significant on SNOT-20scores. There was a strong correlation betweenthe ASBQ, EQ5, and SNOT-20 scores (r>0.5), amoderate correlation between the SNOT-20and EQ5 (r>0.3), while the LKE had only weakcorrelations to any of the QOL scores collected(r<0.3).

Conclusions: Patients who have undergone endoscopicresection of sinonasal tumors have quantifiableQOL results adversely affected by malignanthistology, especially for stages T3 and T4 andpostoperative CRT. These predictive factorsmay guide patient counseling in the preopera-tive period.

3:46PMSinonasal Quality of Life Outcomes afterMinimally Invasive Resection of Sinonasaland Skull Base TumorsBrian Harrow, MSII, BS, Pete Batra, MDDallas, TX

Background: Minimally invasive endoscopic resection (MIER)has emerged as the standard for surgical man-agement of benign and malignant sinonasaland skull base neoplasms. The objective of thepresent study was to assess sinonasal qualityof life (QOL) and to analyze factors that impactsymptomatology after surgery.

Methods: Single-institution observational cohort study wasperformed on 94 patients over a 3-year period.

Results: The mean age of 55.2 years, with male:femaleratio of 1.5:1. Benign and malignant tumorswere observed in 48% and 52%, respectively.The mean preoperative Sinonasal OutcomeTest score (SNOT-20) for the cohort was 1.27,decreasing to 0.90 (p=0.002) 6-months postop-eratively. Patients with benign neoplasms hada lower mean preop SNOT-20 score at 1.11decreasing to 0.64 (p=0.002), while patientswith malignant tumors had a higher mean preopSNOT-20 score of 1.42 decreasing to 1.08(p=0.134) 6 months after surgery. The SNOT-20 scores for females improved 0.53 (p=0.002)compared to 0.23 (p=0.154) for males at 6-months. Statistically significant sinonasal QOLimprovement was noted in non-smokers (0.62,p=0.0006), no prior radiation or chemotherapy(0.59, p=0.0029) and no prior surgery (0.51,p=0.0012). Multiple variable regression analy-sis demonstrated that the two strongest predic-tors for lack of SNOT-20 improvement to beprevious history of smoking (p<0.05) and priorchemoradiation (p<0.01) (R2 = 0.24).

Conclusion: MIER results in overall improvement in SNOT-20 scores, with greater change being noted inpatients with benign tumors and females. Priorsmoking and chemoradiation strongly predictthe lack of improvement in sinonasal QOL aftersurgery.


4:00PMRhinology 2013: What Does the Future Holdfor Rhinology/Sinus Surgery?Invited Speaker: David W. Kennedy, MD

Session: Clinical Practice Update: Is YourPractice Current?Moderators: Naveen Bhandarkar, MD, Erin Wright, MD

4:25PMA Systematic Review of Non-absorbale,Absorbable and Medicated SpacersFollowing Endoscopic Sinus SurgeryXiao Zhao, MD, Aman Grewal, MD, MatthiasBriel, MSc, John Lee, MD, MScToronto, ON


Background: Middle meatal (MM) spacers may reduce adhe-sions following endoscopic sinus surgery(ESS). However, there is no consensus as towhich materials and adjuncts are the mosteffective for this purpose. The primary objec-tive of this study was to examine the effective-ness of absorbable spacers (AS) versus non-absorbable spacers (NAS) in reducing adhe-sions following ESS for chronic sinusitis.Secondarily, we assessed steroidal versus non-steroidal MM spacers in reducing adhesions.

Methods: Following PRISMA guidelines, a systematicreview of randomized controlled trials (RCTs)was conducted and a meta-analysis on relevantoutcome data was performed. Electronic searchwas done using OVID MEDLINE, EMBASE,Cochrane Central register of Controlled Trials,and Web of Science. Independent data extrac-tion and evaluation was conducted.

Results: For our primary objective, 6 RCTs were includ-ed in the systematic review. A pooled estimateof relevant trials revealed a non-significanttrend favoring AS in reducing adhesion forma-tion compared to NAS (RR=0.40, 95% CI 0.15-1.03). This trend was not apparent if NAS areleft for greater than 48 hours after ESS. Forour secondary objective, we identified 4 RCTsthat compared steroidal versus non-steroidalspacers. While a pooled analysis could not beachieved due to inconsistent reporting of MMadhesions, two studies demonstrated signifi-cantly less adhesions in the steroidal spacergroup.

Conclusions: Comparison between NAS and AS showed thatthere was no significant difference in adhesionrates if NAS are used for at least 48 hours aftersurgery. Steroidal spacers may reduce adhe-sions, but more consistent data reporting isrequired for meta-analysis.

4:32PMSystematic Review and Meta-analysis ofTotal Intravenous Anesthesia andEndoscopic Sinus SurgeryAdam DeConde, MD, Christopher Thompson ,MD, Edward Wu, MD, Jeffrey Suh, MDLos Angeles, CA

Objectives/Hypothesis: Systematically review the impact of total intra-venous anesthesia (TIVA) versus inhalationalanesthesia (IA) on visual field, blood loss andcardiovascular parameters during endoscopicsinus surgery.

Study Design: Systematic review and meta-analysis.

Methods: MEDLINE (1950—October 20, 2012) wassearched using a search strategy designed toinclude all randomized controlled trials (RCTs)that discussed TIVA, IA and endoscopic sinussurgery. An abstract search was then used toidentify RCTs directly comparing TIVA and IA inendoscopic sinus surgery. All articles selectedthen underwent full-text review. Data on visualfield scores, blood loss and cardiovascularparameters was then extracted, compared andanalyzed.

Results: There were 42 articles identified by the searchstrategy. Full-text review identified 9 articlesthat met eligibility criteria and containedextractable data. Although inconsistently report-ed, preoperative characteristics (Lund-Mackayscores and history of nasal polyps) were similar(p > 0.05) between the two groups. No differ-ence was found between heart rate, mean arte-rial pressure, anesthesia time, operative time orestimated blood loss. Only 7 studies reported avisibility score, but overall favored the TIVAgroup (p < 0.001).

Conclusions: Current evidence supporting TIVA is limited to ahandful of inconsistently controlled and reportedstudies. Standardized grading of visibility scoresand pre-operative characteristics as well ascost analysis would better establish the role ofTIVA in endoscopic sinus surgery.

4:39PMThe Impact of Neo-osteogenesis on DiseaseControl in Chronic Rhinosinusitis afterPrimary SurgeryPeta-Lee Sacks, MS, Kornkiat Snidvongs, MD,Darren Rom, Peter Earls, MD, Raymond Sacks,MD, Richard Harvey, MDHornsby, NSW


Background:Osteitic bone is a feature of chronic rhinosinusi-tis (CRS), potentially playing a critical role in itspathogenesis. Although seen after previousendoscopic sinus surgery (ESS), it is also adenovo feature in patients without prior inter-ventions. Here, osteitis is associated with hightissue and serum eosinophilia. However, theimpact on prognosis is unclear. This studyinvestigates clinical and endoscopic outcomesbetween patients with and without osteitis afterprimary ESS

Methods:Prospective cohort of previously unoperatedpatients with CRS undergoing ESS was per-formed. Sinuses were scored radiologically forosteitis using the Global Osteitis Scale andKennedy Osteitis Scale preoperatively. Disease-specific quality-of-life (SNOT-22), nasal symptomscore, endoscopic scores (Lund-Kennedy) andclinical outcomes including oral steroid use, fre-quency of nasal washes and infective exacerba-tions were collected at baseline and one yearpost-surgery. The presence and extent of osteitiswas assessed to clinical outcome.

Results:53 patients were included in this study (41.5%female, age 47.4±13.8yrs) of which 42.9% hadfeatures of osteitis on CT. There was no signifi-cant association between the presence norseverity of osteitis at the time of surgery andSNOT-22 or endoscopy scores. However, thepresence of osteitis predicted the need for oralsteroid use post-operatively (p=0.026). High tis-sue eosinophilia could not predict this alone(p=0.55). There was no significant relationshipbetween osteitis and the frequency of steroidirrigations nor infective exacerbations.

Conclusion:Osteitis in CRS is associated with the degree ofeosinophillic activity but as a independentprocess it was associated with little impact of thedisease course.

4:46PMAspirin Desensitization for Samter's TriadNasal Polyposis: A Systematic Review of theLiteratureJason Xu, MSc, Leigh Sowerby, MD, Brian Rotenberg, MD, MPHLondon, ON

Introduction: Nasal polyposis in Samter’s Triad is more likelyto be refractory when treated by traditionalapproaches and have higher rates of recur-rence. Aspirin desensitization may be an effec-tive therapeutic option that targets underlyingdisease etiology. We conduct a systematicreview of the current literature regarding aspirindesensitization treatment for nasal polyposis inpatients with Samter’s Triad.

Methods: All English literature published betweenJanuary 1995 and June 2012 reporting nasaloutcomes following aspirin desensitization inSamter’s Triad patients were eligible for inclu-sion. Exclusion criteria were non-investigative,non-human, and ex-vivo studies. Studies werecategorized by level of evidence and evaluatedfor quality using the Downs and Black scale.

Results: A total of 476 citations were retrieved and 12studies met the criteria for analysis. Outcomemeasurements included self-reported symptomscores, amount of corticosteroid use, rate of revi-sion surgery, and quantitative measurementssuch as rhinomanometry. Overall, most studiesreported a significant improvement in symptomscores, decrease in corticosteroid use, anddecrease in revision surgery. A few studiesshowed promising results with quantitative out-comes. However, most studies were of Level 4evidence with small samples sizes. Rates ofadverse events ranged from 12.5% to 23%.

Conclusions: Unlike traditional treatments for nasal polyposis,aspirin desensitization targets Samter’s Triadetiology rather than phenotype and has poten-tial to be an effective therapeutic option. Whilethe current literature shows positive results,higher quality studies are needed for conclusivebenefit to be demonstrated.


5:00PMClosing Remarks & Meeting Adjourned President and President-Elect: Todd Kingdom,MD, Timothy L. Smith, MD, MPH


A New Paradigm for Managing Epiphora:Endoscopic Evaluation and Treatment of theInferior MeatusJohn DelGaudio, MDAtlanta, GA USA

Objective: Nasolacrimal duct obstruction (NLDO) is a com-mon presenting complaint to the otolaryngologist,and frequently requires surgical intervention bydacryocystorhinostomy (DCR). Evaluation of theinferior meatus (IM) for obstructive pathology hasbeen recently described by the author. We arethe only institution performing routine officeendoscopy of the IM to identify distal NLDpathology, and have reported our experiencewith directed endoscopic treatment of the IM withexcellent results. We will present our diagnosticand treatment paradigm for epiphora.

Methods: Prospectively treated. Adult patients presentingto the author's tertiary rhinology practice withepiphora were routinely evaluated for pathologyat the IM with office nasal endoscopy.Endoscopic findings and surgical outcomes werereviewed.

Results: The majority of evaluated patients had pathologyat the IM, including NLD orifice cysts, mucosalhypertrophy at Hasner's valve, obstructing poly-poid degeneration of inferior turbinates, dacry-oliths, and scar tissue. Endoscopic treatment ofthe specific obstructive pathologies in the IM areless invasive and as effective (>90%) as DCR.

Conclusions: We have found that distal NLDO is found in mostpatients with epiphora and can be attributed to anumber of pathologies in the IM. These patholo-gies are very amenable to a minimally invasiveendoscopic treatment. We recommend endo-scopic evaluation of the IM and the NLD orificein patients with epiphora as part of the standardworkup. We present our diagnostic and treat-ment paradigm for patients with epiphora.

A One-year Comprehensive Study: TheMicrobiology and Antimicrobial ResistancePatterns of Sinus CulturesAnne Cosgriff, MD, Edward Hepworth, MD,Cutler Jeffrey, MD, James Small, MD,Christopher Lind, BSDenver, Colorado USA

Introduction: This study examined the bacteriology of sinuscultures in a rhinology focused practice. A largescale antibiogram of sensitivity and resistancepatterns to commonly tested antibiotics wasdeveloped.

Methods: A retrospective chart review of 274 patients whounderwent 491 cultures for either acute or chron-ic sinusitis within a one year period from 2010 to2011 was performed. Per lab protocol, cultureswere tested against an appropriate subset of 40antibiotics to determine antibiotic sensitivity andresistance patterns.

Results: 87.37% (429 of 491) of cultures grew at leastone organism. Of the 253 patients who hadsuch positive growth, the average age at culturewas 53.28 years. 113 were male, and 140 werefemale. In this population, 648 bacteria were iso-lated. 224 (88.5%) of patients had undergonepast sinus surgery. 76 distinct bacterial specieswere identified. The most frequent isolates were:Staphylococcus aureus (99 were methicillin-sen-sitive and 36 were methicillin-resistant), coagu-lase negative Staphylococcus species, not other-wise designated (75), Staphylococcus epider-midis (66), Pseudomonas aeruginosa (42),Diptheroids (38), Streptococcus pneumoniae(37), alpha hemolytic Streptococcus, not other-wise designated (31), Moraxella branhamellacatarrhalis (30), Haemophilus influenzae (30),Escherichia coli (11), and Streptococcus viridans(11). These isolates accounted for 78.09% ofthe bacteria cultured (506/648).

Conclusion: While 76 bacterial species were identified, themost commonly occurring species includedStaphylococcus, Pseudomonas, Diptheroids, andStreptococcus. To assist in caring for futurepatients in our practice, an antibiogram of oneyear of cultures was developed.

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A Pilot, Open-label Study to Assess theSafety and Performance of a Maxillary SinusOstium Self-Dilation DeviceIain Hathorn, MD, Al-Rahim Habib, BSc,Rachelle Dar Santos, BSc, Eng Cern Gan, MDAmin Javer, MDVancouver, BC Canada

Introduction: The maxillary sinus ostium (MSO) is commonlyobstructed in patients suffering from ChronicRhinosinusitis (CRS) and surgery may berequired to reestablish drainage and ventilation.Recently, a novel osmotic self-dilating expansiondevice has been developed for use in the officeto expand sinonasal ostia without surgical resec-tion. This device has demonstrated safety andsuccessful dilation of sinonasal ostia in an ovinemodel.

Objective: To conduct a pilot study to determine the safetyand feasibility of a MSO self-dilating expansiondevice in human subjects.

Methods: Primary CRS patients presenting with chronicmaxillary sinus inflammation requiring FESSwere enrolled into the study. Each MSO wasevaluated prior to surgery to determine suitabilityof placement. The device was inserted at thestart of surgery and removed after 60 minutes.Endoscopic evaluation for patency was per-formed immediately after removal, at 6 days, 1month, and 3 months postoperatively. Adverseevents were recorded at each visit.

Results: Ten patients (n=18 MSO) were treated in thisseries. 17 (94%) devices remained inserted for60 minutes and achieved a mean dilation to 4.8± 0.5mm. Light bleeding during placement wasreported in 12 (67%) cases. No adverse eventsoccurred during insertion, removal or throughoutthe postoperative recovery. Presently 8 MSOhave been evaluated at 3 months post insertionof which 7 (88%) have been confirmed patent.

Conclusion: Placement of a novel osmotic self-dilating expan-sion device in human MSO is safe, achievableand effective.

A Rare Case of SinonasalHemangiopericytoma: Case Report andReview of LiteratureJonathan Simmonds, BA, Elie Rebeiz, MDBoston, MA , USA

Hemangiopericytomas are soft tissue tumorscomposed of pericytic cells that are character-ized by their, "staghorn" vascular branching andtheir variable clinical presentation. Fifteen to 25%of all HPC occur in the head and neck, with only5% found in the nose or paranasal sinuses.Sinonasal hemangiopericytoma (SNHPC) is con-sidered distinct from its soft tissue counterpart -the former showing a more uniform cellularorganization, has convincing pericytic differentia-tion and is associated with a far better prognosis.With less than 200 cases of SNHPC reported inthe literature, only limited assumptions can bemade about this rare tumor.

Here, we present another case of SNHCP in a42-year-old Chinese woman who presented witha 6-week history of epistaxis from the left side ofher nose and a 1-year history of anosmia. Nasalendoscopy revealed a pulsatile, vascular mass inthe left middle meatus. CT and MRI studiesshow an enhancing mass in the left nasal cavity,with thinning and erosion of the left cribriformplate. Endoscopic biopsy showed a Spindle Cellneoplasm consistent with Hemangiopericytomathat stained positively VEGF, NSE, factor XIIIa,S-100 protein, and CD34, and negative for actin,desmin, CD31, and pankeratin. Embolization ofthe sphenopalatine and labial artery as well asneoadjuvant radiation therapy was performed toshrink the tumor before complete endoscopicresection was performed with negative septaland posterior ethmoidal margins with 250cc ofblood loss. The patient remained free of diseaseon her one-year follow up


Accessory Tragus in the Nasopharynx: CaseReport, Literature Review, and Discussion ofEmbryologic DevelopmentSoroush Zaghi, MD, Leenoy Hendizadeh, BS,Dana Haydel, MD, Jeffrey Koempel, MDLos Angeles, CA, USA

Introduction: An accessory tragus may result from the aber-rant development of the first branchial archbetween the third and seventh weeks ofintrauterine life. Accessory tragi commonly pres-ent in the pre-auricular region near the primarytragus, but they may also present in other moreunusual locations. Here we present the firstknown case of a congenital accessory tragusthat was found in the nasopharynx.

Method: Case report, literature review, and discussion ofembryologic development.

Case: A nine year-old-girl presented with complaints ofnasal airway obstruction, mouth breathing, andloud snoring. On exam, an obvious mass, cov-ered with what appeared to be normal mucosa,was noted extending from the nasopharynx intothe oropharynx. MRI revealed a 1.4 cm hyperin-tense, pedunculated, polypoid lesion adjacent tothe right pharyngeal wall near the level of thepalate. The patient underwent endoscopicresection in the OR. Pathologic analysis con-firmed the mass as a rudimentary accessory tra-gus.

Discussion: Accessory tragi occur with a frequency of 1 to 10per 1000 births and are usually isolated anom-alies. Although they most commonly occur in thepre-auricular region, accessory tragi may alsooccur anywhere along the lateral to medialmigration course of embryologic remnants fromthe first branchial arch. Other atypical locationsfor accessory tragi include attached to theglabella, nasal vestibule, malleus, andEustachian tube.

Conclusion: We present the first described case of accessorytragus in the nasopharynx and provide an educa-tional module to help providers understand theclinical relevance of migration patterns in embry-ologic development.

Ambient Warming of Nasal IrrigationSolutions: Implications for Safe Topical DrugDelivery and Patient ComplianceJanalee Holmes, MD, Timothy Haffey, MD, TroyWoodard, MD, Raj Sindwani, MDCleveland, OH USA

Background: Topical drug delivery for chronic rhinosinusitisusing nasal irrigation or nebulization is gainingpopularity. Paranasal sinus exostoses(PSE)appears to be a complication of cold nasal irriga-tions, akin to exostoses in the ear canal. Manycompounded irrigation solutions require refriger-ation, and patients are advised to irrigate withsolutions at room temperature. However, thetime it takes for common irrigants to adequatelywarm is unknown.

Methods:Standard formulations of common sinonasalmedications and saline were tested. A non-con-tact laser thermometer was used to record tem-peratures within the refrigerator, and at standardintervals until the solutions reached ambient tem-perature. A NasoNeb device was also used andtemperatures pre and post-nebulization wererecorded.

Results: Ambient temperature was 73.5 °F. The averagerefrigerated temperature was 43.5 °F. After 45and 60 minutes of passive warming, the averagetemperature of the solutions was 59.8 °F and62.5 °F, respectively. It took 120 minutes forthese solutions to approach ambient tempera-ture. The rate of warming of the various solutionswas similar. When solutions were nebulizeddirectly out of the refrigerator, they warmed from40.5 °F to 61.7 °F on average.

Conclusion:Although the critical temperature associated withPSE formation is unknown, it seems prudent toadvise patients to leave refrigerated irrigationsolutions at room temperature for at least 45minutes prior to use, or to actively warm them.The protracted time taken for ambient warmingmay impact patient compliance for using solu-tions at room temperature. Temperature appearsless of an issue with nebulized drug delivery.


Analysis of 1200 Endoscopic Draf IIa FrontalSinusotomies: Intraoperative Findings andResultsAllison Fry, BS, Wade Han, MDOrlando, FL USA

Frontal sinus outflow stenosis is common follow-ing functional endoscopic sinus surgery (FESS).Anterior ethmoidectomy in patients with a hyper-cellular frontoethmoid region may lead to iatro-genic adhesion or synechia obstruction of anotherwise patent but narrow frontal sinusdrainage pathway. Endoscopic Draf IIa proce-dure, with removal of all frontoethmoid cells, isone of the techniques to improve frontal outflowpatency. In this study, we retrospectivelyreviewed 1200 consecutive completed andattempted Draf IIa frontal sinusotomies per-formed at a community based general otolaryn-gologic practice during 2010-2012. Intraoperativefindings were analyzed from operative notes andstill images taken with a 70 degree rigid nasoen-doscope at the end of the frontal surgery. Whenavailable, postoperative symptom scores andpostoperative angled endoscopic findings offrontal sinusotomies were tabulated. Over 95%of post-Draf IIa patients are frontal symptom freewith a follow up period of at least 6 months.When indicated postoperatively, in office 70degree endoscopic examination and sinus CTimages generally showed patent frontal sinusoutflow tracts. Routine Endoscopic Draf IIa inte-grated with FESS is a viable approach with a lowincidence of post operative frontal drainageobstruction and subjective symptoms.

Cemento-Ossifying Fibroma of the Skull BaseToby Steele, MD, Edward Strong, MDSacramento, California USA

Introduction:Cemento-Ossifying fibroma(COF) is a rarebenign osseous lesion originating from the cran-iofacial skeleton. While the majority of theselesions arise within the mandible, less commonsites include the maxilla, paranasal sinuses, orbitand skull base. With fewer than 100 reportedcases in the literature, we present a case of COFarising from the skull base.

Case Description:A 20 year old male presented in January of 2012with a one year history of progressive left orbitalpressure, headache, and proptosis. Physicalexamination revealed exophthalmos andhypophthalmos. Extraocular movements wereintact x 6 and facial animation and sensationwere normal. CT revealed 4.0 x 3.4 x 2.3 cmhomogeneous mass arising within the roof of theleft orbit. The mass had a well-circumscribed thinrim and contained a few coarse calcifications.

After consultation with the Neurosurgical team,the patient underwent a bicoronal approach for aleft frontal craniotomy, tumor resection, andreconstruction with a pericranial flap and con-toured MESH implant. The patient's post-opera-tive course was uneventful, and post-operativeCT confirmed complete tumor resection with sat-isfactory orbital roof reconstruction. Histologicalsections showed proliferation of spindle cellswith bland nuclei and production of round to ovalcemento-ossifying material. There were nomalignant cells identified.

Discussion:COF is a rare benign osseous lesion that oftenrepresents a diagnostic dilemma for the surgeonand pathologist. The tumor may present withcosmetic deformity, infection, proptosis,sinonasal obstruction, and rarely intracranialcomplications. Complete surgical resection isnecessary to prevent recurrence and surveil-lance imaging is recommended.


Central Skull Base Osteomyelitis: AnEmerging Clinical EntityAndrew Johnson, MD, Pete Batra, MDDallas, TX USA

Background: Skull base osteomyelitis (SBO) most commonlyresults as a complication of otitis externa in dia-betic patients. Central or atypical presentations,unrelated to aural pathology, have been docu-mented, though restricted to small patient seriesor case reports. The current study systematicallyanalyzed the literature to construct the clinicalprofile of this rare but potentially fatal entity.

Methods: The Medline (Ovid) database was searched forall published cases of central SBO. Statisticalanalysis was performed to identify trends affect-ing overall outcomes or differences in treatment.

Results: A total of 43 cases were included with mean ageof 52 years and male:female ratio of 2.3:1. Themost common cranial nerve palsies included VI(33%) followed by IX (30%) and X (30%).Staphylococcus aureus (21%) and P. aeruginosa(21%) were the two most common causativepathogens. The mean duration of antimicrobialtherapy was 21 weeks, with 70% requiring IVantibiotics for a mean duration of 6.9 weeks.Nineteen of 43 patients (44%) required adjunctsurgical debridement. The overall mortality was9%, with additional 34% experiencing disease-related complications. Women were more likelythan men to require multiple courses of therapy(46% vs 10%, p = .01). History of cardiovasculardisease correlated with longer duration of thera-py (54.8 vs 14.3 weeks, p = .02).

Conclusion: Osteomyelitis of the central skull base remains arare, highly morbid disease that poses significantchallenges for timely and accurate diagnosis andtherapy. Females and those with pre-existingcardiovascular disease may require longercourses of therapy to optimize care.

Cerebrospinal Fluid Leak - a NovelMechanism of Injury to a Well KnownComplication of SeptorhinoplastyMamie Higgins, BA, Abib Agbetoba, MD, KevinYao, MD, FACS, Michael Shohet, MD, FACSBuffalo, New York USA

Background:Septoplasty represents one of the most com-monly performed rhinologic procedures in oto-laryngology. Associated complications havebeen well documented in literature with cere-brospinal fluid (CSF) leak representing one ofthe most rare and potentially fatal outcomes. Wepresent a case report of an iatrogenic CSF leakoccurring in the sphenoid sinus following a sep-torhinoplasty procedure as well as a review ofthe literature on iatrogenic CSF leaks.

Methods: Case report and literature review. The patient'smedical records, computerized tomography (CT)imaging, magnetic resonance imaging (MRI),and original operative report were reviewed.

Results: A 48 year-old female underwent septorhinoplastyat an outside facility complicated by postopera-tive CSF rhinorrhea two weeks following the pro-cedure. Given progression of ventriculomegaly,hydropneumocephalus, and persistence of ananterior sellar floor defect, the patient ultimatelyunderwent endoscopic exploration and repair.Intraoperatively pulsatile CSF was immediatelyvisualized from a defect at the face of the sphe-noid just medial to the natural ostium. Uponentry into the sphenoid sinus, defect of the ros-trum was noted and a 1 cm defect was easilyexposed at the sellar floor. A repair with pedicledposterior septal flap and free middle turbinateosteomucoperiosteal graft and subsequent CSFshunting resulted in clinical resolution.

Conclusion: CSF leak following surgical procedures of thenasal septum represent rare and potentially fatalcomplications. The case described represents aunique case of iatrogenic CSF leak occurring atthe anterior sellar floor following a septorhino-plasty operation. Potential mechanisms andtreatment options are detailed.


Chronic Granulomatous Invasive FungalSinusitis With Intracranial Extension-A CaseReport and Review of the LiteratureAshleigh Halderman, MD, Raj Sindwani, MDCleveland, OH USA

Introduction: Chronic granulomatous invasive fungal sinusitis(CGIFS) is a rare clinical entity in North America.There is no consensus in the literature on theideal method of surgical and/or medical manage-ment of CGIFS. Traditionally, aggressive surgicalresection and long term IV Amphotericin B havebeen used. We present a rare case in which apatient with extensive orbital and intracranialCGIFS was managed successfully with a conser-vative approach.

Methods: Case report and review of the literature.Results: A 48 year old African American malepresented with unilateral headache, proptosis,papilledema, and facial paresthesias. Imagingrevealed an infiltrative process with extensiveintracranial and orbital involvement. Biopsyshowed fungal elements associated with a gran-ulomatous reaction without angioinvasion or sig-nificant necrosis consistent with the diagnosis ofCGIFS. Aspergillus fumigatus was cultured.Aggressive surgical resection would have result-ed in significant morbidity and possible mortality.Therefore, the decision was made to managewith conservative surgical debridement and longterm oral Voriconazole. The patient's symptomsand exam findings slowly resolved and he hadalmost complete resolution of disease on MRIafter 8 months of therapy.

Conclusion: There is no consensus on the ideal managementof CGIFS, and treatment should be individual-ized. This case and the recent literature supporta more conservative surgical approach in somepatients with extensive CGIFS. The use of oralVoriconazole is effective and has significantadvantages over more toxic and intravenouslyadministered agents.

Clinical and Anatomic Characteristics ofPatients with Complications of AcuteRhinosinusitisIlya Likhterov, MD, Megan Durr, MDCathleen Kenary, BS, Steven Pletcher, MDSan Francisco, CA USA

Background: Acute rhinosinusitis is a common disorder withrare yet serious complications. Risk factors forthe development of orbital and intracranial com-plications of acute sinusitis remain largelyunknown. The purpose of this study is to evalu-ate whether increased aeration of the sinuses isassociated with developing complications ofsinusitis. The frontal sinus volume is used as ametric for overall sinus aeration.

Methods: This is a retrospective comparison of thirtypatients (17 pediatric and 13 adult) treated at anacademic medical center for complications ofacute rhinosinusitis with thirty age and sexmatched controls. Frontal sinus volumes werecalculated from computer tomography scansusing commercially-available software.

Results: Pediatric patient with complications of sinusitishad increased aeration of their frontal sinusescompared to controls (p<0.05). This differenceremained significant when using disease-matched (sinusitis without complications) con-trols. No difference in frontal sinus volumes wasfound in adult patients with complications ofsinusitis when compared to age and sex-matched controls.

Conclusion: Anatomic variations of sinus aeration are associ-ated with the development of complications ofacute sinusitis in the pediatric population. Thisstudy demonstrates a specific association offrontal sinus volume with complications of acutesinusitis which may reflect an association ofsinus hyper-aeration to the development of com-plications.


Clinical and Pathologic Characterization ofNasal Abuse of Opioid-acetaminophenMedicationsPeter Vosler, MD, PhD, Stella Lee, MD, JorgeContreras, MD, Eric Wang, MD, Barry Schaitkin,MD, Berrylin Ferguson, MDPittsburgh, PA USA

Background: The nasal abuse of crushed opioids and aceta-minophen is a growing problem, frequently lead-ing to nasal necrosis and fungal colonization.Failure to recognize the underlying cause of fun-gal colonization may lead to inappropriate pro-longed antifungal therapy, as has been advocat-ed by other studies.

Objective: To increase awareness of the typical presenta-tion of intranasal opioid-acetaminophen abuse,and outline optimal therapy.

Methods: Retrospective case series and literature review.

Results: Seven adults ranging in age from 23 to 46 yearsseen between January to October of 2012 withnasal complaints were subsequently discoveredto be using intranasal opioid-acetaminophendrugs. All patients presented with nasal pain.Intranasal endoscopic exam showed fibrinousdebris and tissue necrosis in all patients. Septalperforation was seen in 6/7 (85.7%) patients.Pathology/culture revealed the presence of fun-gus in 6/7 (85.7%) of patients. Unlike previousreports, no tissue invasion by fungus was found.Systemic antifungals and intranasal antifungalirrigations were started in 3 patients without clearbenefit. Polarizable material was seen in 4/7(57.1%) of the pathology specimens. Patientswho abstained from intranasal drug use withconcomitant repeated debridement demonstratedthe greatest improvement.

Conclusion: Intranasal opioid-acetaminophen abuse causesnasal pain, tissue necrosis, high risk of septalperforation, and fungal colonization. Antifungaltherapy was of no benefit in the current series ofpatients in contrast to previous reports. Therapyshould include debridement, and most important-ly, cessation of intranasal opioids-acetamino-phen, which often requires drug rehabilitation.

Clinical Manifestations of Granulomatosiswith Polyangiitis (GPA: Wegener's granulo-matosis) in the Upper Respiratory Tracts byOtolaryngologists of JapanYasuaki Harabuchi, MD, PhD, Kan Kishibe, MD,PhD, Yuki Komabayashi, MDAsahikawa, Hokkaido Japan

Patients enrolled in this study consisted of total91 patients with GPA who were dealt by otolaryn-gology in Japan. Of all 91 patients, 56% patientssuffered in upper respiratory tract (URT) alone.As the findings of PR3-ANCA, histology and ini-tial diagnosis, of 40 patients involving sites otherthan URT, 64% and 73% were positive for PR3-ANCA and histology, respectively. On the otherhand, of 51 patients involving URT alone, only49% and 31% were positive for PR3-ANCA andhistology, respectively. With regard to diagnosis,definitive and probable diagnoses were done in78% and 20% patients involving sites other thanURT, respectively. On the other hand, definitiveand probable diagnoses were done in only 22%and 37% patients involving URT alone, respec-tively. Forty one percents were inapplicable todiagnostic criteria of Japan. Of 21 patients whowere inapplicable to the diagnostic criteria, 13(62%) patients developed additional symptomsand signs during observation period, and thenthey got into the diagnostic criteria in Japan. Inthese patients, MPO-ANCA positive cases werefound in 8 patients and 3 patients have equaland more than 2 sub-lesions in the upper respi-ratory tracts. If the diagnostic criteria includes thecases with MPO-ANCA(+) and 2 lesions of URT,of 21 patients without criteria 11 patients enteredthe criteria, then diagnostic rate will increase to86% from 59% even though limited form. Thusabout 60% of the patients with symptoms ofupper respiratory tract alone did not satisfy theJapanese diagnostic criteria at the initial visit.


Clinical Outcome of Middle TurbinateResection During Endoscopic Sinus Surgery:A Systematic ReviewGarret Choby, MD, Candace Hobson, MD, Stella Lee, MD, Eric Wang, MDPittsburgh, PA USA

Introduction: The middle turbinate (MT) is often preservedduring endoscopic sinus surgery (ESS) in aneffort to maintain nasal physiology and as a use-ful anatomic landmark. However, resection isperformed in select cases due to involvement ofthe MT in the inflammatory process, obstruction,or instability. Controversy exists regarding theeffects of middle turbinate resection and the ben-efits of preservation. The purpose of this sys-tematic review is to evaluate the evidenceregarding middle turbinate resection in patientsundergoing ESS for chronic rhinosinusitis (CRS).

Methods: A systematic review of the literature was per-formed for publications examining clinical out-comes of MT resection during ESS performed forCRS. Inclusion criteria included adult patientpopulation (=18 years old), history of CRS, level2B or higher evidence and defined clinical out-come: synechiae, bleeding, revision rates, olfac-tion, and symptom scores.

Results: 6 articles met inclusion criteria and were includ-ed in this review. There were a total of 507patients studied over 1 prospective randomizedcontrolled trial, 2 prospective non-controlled trialsand 3 prospective observational studies. Although the studies are quite heterogeneous,they suggest that MT resection does not signifi-cantly adversely affect patient quality of life com-pared to MT preservation and may benefit visual-ization during post-operative debridement.

Conclusions: Due to the small number of patients and hetero-geneity of data reported in the studies evaluated,the clinical outcome of middle turbinate resectionremains unclear. In the small number of studiesmeeting inclusion criteria, it does not appear thatMT resection negatively impacts clinical outcomefollowing ESS.

Clinical Outcome of the use of Nasal PackingFollowing Endoscopic Sinus Surgery forChronic Rhinosinusitis: A Systematic Reviewand Meta-analysisCandace Hobson, MD, Garrett Choby, MDStella Lee, MD, Eric Wang, MDPittsburgh, PA USA

Introduction: The objective of this systematic review was toevaluate the outcomes of patients who under-went packing of the middle meatus at the com-pletion of endoscopic sinus surgery (ESS) forchronic rhinosinusitis (CRS).

Methods: Prospective randomized controlled studies ofpatients who underwent packing of the middlemeatus at the completion of ESS were reviewedand included for meta-analysis. Outcome meas-ures extracted and analyzed included rates ofsynechiae, middle meatal patency, presence ofinflammation, and quality of life measures (nasalobstruction, facial pain, headache). We com-pared the use of packing versus no packing andthe resulting effect on surgical outcomes.

Results: Seventeen prospective, randomized, controlledtrials met inclusion criteria resulting in a total of865 subjects. Middle meatal packing of any type,including absorbable and non-absorbable, wasassociated with a decreased risk of synechiaeformation (RR = 0.544); however, this did notachieve statistical significance (p=0.052) onmeta-analysis. The data for middle meatal paten-cy, nasal obstruction, inflammation, and facialpain/headache were too heterogeneous to beanalyzed for statistical significance

Conclusions: This systematic review reveals that nasal pack-ing does not significantly affect the risk of adhe-sions after ESS. Data evaluating the surgicaloutcomes of middle meatal patency, nasalobstruction, inflammation, and facialpain/headache were inconsistently measured inthe studies included, and were thus not suitablefor meta-analysis.


Clinicodemographic and HospitalCharacteristics Associated with thePresentation of Acute Bacterial SinusitisComplications in AdultsAhmad Sedaghat, MD, PhD, Stacey Gray, MD,Stacey Ishman, MD, MPHBoston, MA USA

Background: Acute rhinosinusitis (ARS) is a common complica-tion of upper respiratory infections. Despite antibi-otic therapy, some cases of ARS will becomecomplicated by orbital or intracranial involvement.

Methods: Cross-sectional analysis of the 2008 NationwideEmergency Department Sample (NEDS) data-base using all patients older than eighteen yearsold with a diagnosis of ARS. Factors associatedwith ARS complications such as patient character-istics (age, gender, comorbid conditions, familyincome level and insurance type) and hospital-specific characteristics (geographic location, urbandesignation and teaching status) were identified.

Results: 564,662 patients were included, 551 (0.1%) ofwhom were diagnosed with an orbital or intracra-nial complication of ARS. Male gender (odds ratio[OR]=1.84, P<0.001), a concomitant diagnosis ofchronic rhinosinusitis (CRS) (OR=8.32, P<0.001)or comorbidities including HIV infection, lym-phomas, leukemias, cystic fibrosis, and/or immunedisorders (OR=2.27, P=0.024) as well as presen-tation to metropolitan teaching (OR=2.05,P<0.001) and non-teaching (OR=6.53, P<0.001)hospitals were associated with complications.Although patients from the lowest income groupswere least associated with ARS complications, noparticular socioeconomic trend was observed insubgroup analysis of patients with periorbital cel-lulitis, orbital complications or intracranial compli-cations. The only consistent association with allsubgroups of ARS complications was a concomi-tant diagnosis of CRS.

Conclusions: Complications of ARS in adults are associatedwith CRS as well as comorbidities including cys-tic fibrosis or immunodeficiencies. The index ofsuspicion for ARS complications should beraised in these patients to improve outcomesthrough timely diagnosis and treatment, in partic-ular in a patient population that may not toleratesuch illness.

Differences in Skull Base Thickness inPatients with Spontaneous CSF LeaksAlkis Psaltis, MD, PhD, Lewis Overton, BS,Nessa Fox, BS, Rodney Schlosser, MDCharleston, SC USA

Aim:Spontaneous cerebrospinal fluid (SCSF) leaksare increasingly recognized as one of the mostcommon etiologies of CSF leak. They are asso-ciated with increased intracranial pressures andoften present with unique clinical and radiologicalfeatures. This study evaluates the skull basethickness in SCSF patients.

Methods:CT scans of 95 patients were evaluated by 2blinded observers. The anterior skull base bonythickness was compared at consistent locationsin different planes for 32 patients with SCSFleaks, 26 patients with traumatic leaks and 37race-matched controls.

Results:SCSF were most common in the sphenoid inAfrican Americans and in the ethmoid roof inwhites. The sella was significantly larger andthinner in African Americans (p<0.05).Irrespective of race, patients with SCSF leakshad larger sellas and thinner skull bases in thelateral lamella and ethmoid roof regions, meas-ured coronally, and in the ethmoid roof and sphe-noid planum regions, measured sagittally(p<0.05).

Conclusion:Patients with spontaneous CSF leaks have thin-ner skull bases in several locations when com-pared to patients with traumatic leaks andhealthy controls. Whether this thinner skull basepredisposes to spontaneous CSF leaks or is aconsequence of the underlying increased CSFpressure remains unknown.


Distal Spontaneous Pseudomeningoceles ofthe Skull BaseSeth Lieberman, MD, Roy Casiano, MDMiami, FL USA

Introduction: A pseudomeningocele is a collection of cere-brospinal fluid (CSF) in the soft tissue that is notsurrounded by arachnoid membranes. The fol-lowing represents the first reported cases ofnasopharyngeal pseudomeningoceles trackingsubmucosally to the sphenoid sinus.

Methods: Case series

Results: Two examples of distant spontaneouspseudomeningoceles of the skull base arepresented. In one case, the CSF leak wascontained behind the mucosa of the Eustachiantube. At the time of surgery, the patient was nothaving active CSF rhinorrhea. With the aid ofintrathecal fluorescein, the leak was trackedback to the vidian canal and sphenoid sinus. Anasoseptal flap was used for a repair. In theother case, the patient was actively leaking atthe time of surgery. The leak was found on thedorsum of the soft palate. The fistula wastracked submucosally to the lateralnasopharyngeal wall and ultimately to the vidiancanal. This was repaired with an underlay bonegraft. Both patients had elevated CSF pressuresand were managed with a shunt. Both patientshad complicated courses of their disease withmultiple episodes of preoperative andpostoperative meningitis.

Conclusion: Spontaneous CSF leaks from the skull base cantrack submucosally to areas distant from the skullbase. These pseudomeningoceles may be associ-ated with elevated intracranial pressure and,though rare, may be an underrecognized entity.

Dysgeusia, Dysosmia, Depression, and Drugsin Chemosensory DisordersMichael Stevens, MDSalt Lake City, UT USA

Introduction:Dysgeusia and dysosmia can impact quality oflife, but also cause malnutrition.

Materials and Methods:Forty five patients with dysgeusia and ordysosmia were followed prospectively for up to 4years to observe their outcome. Depression waspresent in 46.6% of patients. The etiology of theirdysgeusia and or dysosmia included drugs in 8,viral in 7, recurrent sinus infections in 3, 2 eachdue to sinus surgery, diabetes mellitus,tonsillectomy, and chemotherapy, and 1 eachwith head injury, graves disease, depression,brain surgery, and multiple causes. There were10 whose etiology could not be determined.Each patient was given a smell and tastequestionaire, nasal endoscopy, and a CT or MRIscan. A smell identification Test along with tastetesting was done on each patient. A screeningneurological exam was done along with bloodtests on patients whose problem was of unknowncause. Zinc sulfate, sertraline hydrochloride, andgabapentin were offered to patients that did notrespond to stopping or changing drugs that mightbe the cause of their symptoms.

Results: Eight of twenty six patients were cured by chang-ing or stopping current medication. Six of sixteenthat took Zinc, five of eleven that took Zoloft, and2 of 6 who took Gabapentin had symptoms elimi-nated. There were 16 whose symptomsresolved spontaneously.

Conclusion:Thirty five of forty five or 77.7% of patients hadcomplete resolution(25) or dramatic improve-ment(10) of their symptoms. Therefore, the out-look for these patients is good.


Endoscopic Drainage of an Epidural Abscessfrom Sphenoid Sinusitis in a 3-Year Old ChildCaroline Kolb, MD, Benjamin Cable, MD, Stacey Wolfe, MDHonolulu, HI USA

Introduction: Epidural abscess is an infrequent complication ofpediatric sinusitis in patients younger than sevenyears old due to the later development of thesphenoid and frontal sinuses. Abscesses inteenagers in the frontal region secondary tofrontal sinusitis are most commonly reported.

Methods: We present a rare case of a 3-year old malepresenting with mental status changes, fever,and lethargy. Imaging confirmed sphenoidsinusitis culminating in an epidural abscess ofthe middle cranial fossa. A transsphenoidalapproach was used to perform endoscopicdrainage of the epidural abscess.

Results: Endoscopic transsphenoidal drainage of theepidural abscess was successfully performedwithout the need for craniotomy or otherneurosurgical interventions. We discuss thetechnique and provide a video complement toillustrate the procedure. We review the literatureon the success of endoscopic drainage ofepidural abscesses as complications of pediatricsinusitis.

Conclusion: This case demonstrates the feasibility ofendoscopic transsphenoidal drainage of a middlecranial fossa epidural abscess. This approachmay offer a safe and effective alternative to ahigh-risk craniotomy in selected cases.

Endoscopic Orbitotomy: Indications andOutcomesJanalee Holmes, MD, Divya Gumber, BS, Jastin Antisdel, MD, Raj Sindwani, MDCleveland, OH USA

Objectives: Performing surgery on the orbit throughminimally invasive approaches has gained favor.Although the orbit is most commonly approachedendoscopically in the management of Graves'orbitopathy via orbital decompression, a varietyof other indications are emerging which usesimilar techniques.

Methods: CPT codes for endoscopic orbital decompressionperformed between 2002 and 2011 at two majorcenters were retrospectively reviewed. Patientswith a diagnosis of Graves' disease or orbitalcomplication of sinusitis were excluded.Presenting symptoms, operative technique,lesion location, pathology, and postoperativecomplications were recorded. Results: During the study period a total of 126patients had orbital decompressions, with 26patients meeting inclusion criteria. The majorityof patients (17/26) were men, and the averageage was 57 (14-88) years. Seventeen patientshad solitary orbital lesions isolated to the apex.Nine had sinonasal lesions that directly involvedthe lamina papyracea and required resection.Diverse etiologies were encountered: includingbenign (34.6%), malignant (50%), andinflammatory (7.7%). Obtaining a pathologicdiagnosis was successful endoscopically in allbut two (7.7%) patients. Both of these patientshad lesions that were predominantly lateral tothe optic nerve. Postoperatively one elderlypatient suffered a myocardial infarction. Nocases of CSF leak, hemorrhage, or new-onsetblindness were experienced.

Conclusion: Accessing the orbit endoscopically enablessurgeons to safely and effectively biopsy andmanage a variety of pathologies involving themedial orbit and apex. This approach offersmarked advantages over external techniquesincluding avoidance of retraction on the opticnerve, superior visualization, and the avoidanceof a facial scar.


Evaluation of Skull Base Reconstruction andSinonasal Disease Following EndoscopicSkull Base Surgery with Radiation TherapyCristine Klatt-Cromwell, MD, Travis Newberry,MD, Matthew Ewend, MD, Brent Senior, MD,Charles Ebert, MD, Adam Zanation, MDChapel Hill, NC USA

Background:Endoscopic skull-base surgery and vascularizedreconstructions has advanced and becomeapplicable to sinonasal/skull base cancers andinvasive benign tumors. Adjuvant radiation forinvasive processes offers significant clinicalbenefit for tumor control. The aim of this study isto assess changes to nasoseptal flap (NSF)reconstructions and sinus mucosa afterendoscopic skull-base surgery with radiation.

Methods:Patients with endoscopic skull-base and duralresection, NSF reconstruction and radiation withpost-therapy MRIs were identified over a four-yearperiod. Post-therapy scans were evaluated forenhancement and contracture of NSF and sinusdisease evaluated via Lund-Mackay scoring.Vascularity was compared to inferior turbinatemucosa via intrascan pixilated signal intensity.

Results:Sixteen patients, 10 males, 6 females, ages 10-76, were identified. Nine of sixteen surgeries werefor malignancies and all reconstructionsdemonstrated initial vascularization. Five patients(31.6%) had congested uptake in NSF followingradiation, but all were vascularized. Of these, twodemonstrated congestion prior to radiationtherapy. Average contracture was minimal at0.03mm. Twelve patients demonstrated mucosalthickening in the sinuses (average LM = 1.93),with 8 demonstrating primarily sphenoid disease.One patient had repeat surgery for vestibularstenosis. No patients reported sinus symptomsthat required repeat surgery. No flap deaths orCSF leaks were noted.

Conclusion:Endoscopic surgery with NSF reconstruction fol-lowed by radiation is safe without need for revi-sion sinus surgery or CSF leak repair. NSFreconstruction after radiation maintain vascularitywith minimal contraction. This populationdemonstrates mucosal thickening most common-ly in the sphenoid sinus following radiation, how-ever do not require revision surgery.

Frontal Sinus Mucocele as a LateComplication of Frontal Bossing ReductionJiovani Visaya, MD, Nicole Hsu, MD, Rita Roure, MD, Aaron Pearlman, MDNew York, NY USA

Introduction: Supraorbital prominence (frontal bossing) is arelatively rare cosmetic deformity associated withhypertrophy of the frontal sinus. Various surgicaltechniques have been described to address thisdeformity, including bone contouring/abrasion,setback osteotomies, and inversion of the anteri-or table. Although such techniques may poten-tially disrupt the underlying mucosa and interferewith normal sinus function, their long-term com-plications have not been well described.

Methods:Case report

Results: A 38-year-old gentleman presented to the emer-gency department with intermittent right frontalheadache for several years. He suffered frombody dysmorphic disorder and had undergonefrontal bossing reduction in the DominicanRepublic 18 years ago. Physical examinationrevealed flattening of the forehead with a well-healed bicoronal incision. On nasal endoscopy,polypoid disease was present in both nasal cavi-ties and obstructed visualization of the middleturbinates. Sinus imaging revealed bilateral anteri-or table defects overlying the frontal sinuses, withopacification of the right frontal, ethmoid, andmaxillary sinuses. Despite completing an oral regi-men of antibiotics and steroids, repeat imagingdemonstrated a right frontal mucocele with per-sistent right ethmoid and maxillary sinus disease.

Conclusion: Frontal mucocele may occur as a late complica-tion of frontal bossing reduction. When perform-ing surgical correction of supraorbital promi-nence, care should be taken to maintain theintegrity of the frontal sinus mucosa in an effortto prevent mucocele formation.


Impact of Intraoperative HydrodebriderTreatment on Postoperative SinonasalInflammationOswaldo Henriquez, MD, Jennifer Mulligan, PhD,Alkis Psaltis, MD, Eric Wang, MD, Shaun Nguyen, MD, Rodney Schlosser, MDCharleston, SC USA

Introduction: The impact of intraoperative hydrodebrider sinusirrigation (HSI) during endoscopic sinus surgery(ESS) upon postoperative inflammation,endoscopy and patient reported outcomes hasnot been studied.

Methods: Twelve patients with symmetric chronic rhinosi-nusitis were prospectively randomized to HSI onone side after undergoing ESS. The contralateralside served as internal control. Preoperative CT,endoscopic, SNOT-22 and symptom visual analogscores (VAS) for each side were obtained. At 1, 3and 6 months post-surgery, endoscopy, SNOT-22and sinus VAS were recorded. Sinonasal mucosalsecretions levels of IL-6, IL-17a and TNFa weremeasured at the time of surgery, 1 and 3 monthspost-operatively from each side.

Results: Endoscopy, SNOT-22 and VAS scores improvedon both sides (p<0.05) at all postoperativetimepoints (p<0.05). HSI had no impact uponpost-operative endoscopy or VAS at any timepoint. HSI significantly decreased IL-6 levelswhen compared to the control side at 1 month (-1410 pg/ml vs.+ 195.4 pg/ml, p=0.01) but not at3 months (-1922 pg/ml vs. -658.4 pg/ml, p=0.46).Both control sides and HSI treated sidesdemonstrated decreased IL-17a at 1 and 3months (p<0.05), however there was no addedbenefit seen with HSI treatment. No significantchange was seen in TNFa on either side at anytime point.

Conclusion:Intraoperative HSI at the time of ESS improvesshort-term postoperative inflammation as meas-ured by IL-6 levels. The direct clinical impact ofthis finding and which patients are most likely tobenefit warrants further investigation.

Incidence, Predictors, and Variation ofConcomitant Nasal and Sinus Surgery, 2000-2009Melissa Pynnonen, MD, MS, Gordon Sun, MD, MSAnn Arbor, MI USA

Introduction: In light of increasing rates of both sinus andnasal operations, we undertook this study todescribe the frequency of concomitant surgerywith endoscopic sinus surgery. We sought toexplore potential predictors of concomitant nasalsurgery.

Methods: We performed a secondary analysis of the StateAmbulatory Surgery Database of Florida, 2000-2009. This dataset represents a 100% sample ofambulatory endoscopic sinus operations duringthis time.

Results: Within this 10 year period there were 114,372adult cases of endoscopic sinus surgery. Afterexcluding those with missing data, and thosecases representing advanced endoscopicprocedures, we had 93,724 observations foranalysis. We found that the population-standardized incidence of concomitant surgeryhas increased over 2000-2009 and that thestrongest predictors of receipt of concomitantsurgery are the surgeon's frequency ofperforming concomitant surgery and thesurgeon's sinus surgery case volume.

Conclusion: Concomitant nasal surgery is common and isbeing performed more commonly than ever. Wehave identified patient, physician, and regionalfactors associated with receipt of concomitantnasal surgery. More research is needed to betterunderstand these factors.


Indications and Outcomes for the DrafIIBFrontal SinusotomyJustin Turner, MD, PhD, Reza Vaezeafshar, MD,Peter Hwang, MDNashville, TN USA

Background:Advanced frontal surgery techniques are oftenrequired when patients fail maximal medicaltherapy and standard endoscopic surgicalapproaches. Unlike other extended approaches,postoperative outcomes and indications for theDrafIIB frontal sinusotomy have not beenextensively reported.

Methods:Patients undergoing the DrafIIB frontalsinusotomy between 2007 and 2012 wereidentified by retrospective chart review. Datacollected included demographics, imaging, sinuspatency, and SNOT-20 scores.

Results:A total of 18 patients were identified with surgeryperformed on a total of 22 frontal sinuses. 13 of18 patients had received previous sinus surgery.The most common indications for the extendedapproach were lateralized middle turbinateremnant (8), mucocele (6), postoperativesynechiae (5), and frontal sinus mass (3). Sinusostium patency was maintained in 19 of 22sinuses over an average follow-up period of 12.4months. No complications were reported.

Conclusions: The DrafIIB frontal sinusotomy is a relatively safeprocedure with multiple indications. Long-termsinus ostium patency was maintained in the vastmajority of operated sinuses, suggesting that theDrafIIB procedure may present an acceptablealternative to more aggressive extended frontalsinus approaches in select patients.

Invasive Fungal Sinusitis: A 12-year reviewNipun Chhabra, MD, Eric Holbrook, MD,Stacey Gray, MDBoston, MA USA

Objectives:We report on a series of patients afflicted withinvasive fungal sinusitis (IFS). At the conclusionof this presentation, participants should be ableto discuss the characteristics and clinicalfeatures of invasive Aspergillus andMucormycosis of the paranasal sinuses.

Study Design:Retrospective case series and review of theliterature

Methods:Over a 12-year period at a single tertiary careinstitution, 13 cases of IFS were identified. Wereview the pertinent etiology, clinicalmanifestations, diagnosis, and treatment of theseaggressive mycoses and their associatedcomplications.

Results:After invasive mycosis was suspected byradiographic and clinical workup, surgicalexploration and biopsy confirmed Mucor andAspergillus in seven and six patients,respectively. The most common comorbidity wasdiabetes mellitus. Two patients had severeperiodontal disease extending to the maxillarysinus as the inciting event, which is a rareetiology of IFS. Treatment included amultidisciplinary approach with systemic therapyand aggressive surgical debridement whenpossible. The mortality rate due to IFS alonewas 30%.

Conclusions:In select hosts fungal species may becomeopportunistic and invasive, resulting in severemorbidity or mortality. The occurrence of IFShas been increasing over the past severaldecades. Aspergillus and Mucor employ avariety of immunoevasive mechanisms to gainadvantage over their hosts. A high index ofclinical suspicion coupled with an early andaggressive combination of medical therapy,surgical intervention, and an understanding ofthe underlying immunologic competency of thepatient is the best regimen to reduce morbidity.


Lobular Capillary Hemangioma of the InferiorTurbinateMike Sheu, MD, MPH, Ling Zhou, MD, Richard Lebowitz, MDNew York, NY USA

Objectives: 1)To describe an unusual presentation of lobularcapillary hemangioma of the inferior turbinate2)A review of the literature regarding lobular cap-illary hemagionma in the nasal cavity

Study Design:Case report and review of the literature

Methods:A 32 year old female presented to the ENT clinicwith a complaint of recurrent epistaxis over sev-eral months. Examination of the nasal cavity wassignificant for a friable vascular lesion emantat-ing from the inferior turbinate. A correspondinglesion was found on CT imaging. She was takingto the OR for complete resection of this lesionincluding subtotal resection of the inferiorturbinate.

Results:Final pathology of this lesion was consistent withlobular capillary hemangioma.

Conclusion:Lobular capillary hemangioma is a uncommonvascular lesion of the nasal cavity. To the best ofour knowledge, an origin on the inferior turbinatehas not previously been described for this lesion.Lobular capillary hemangioma should be consid-ered in the differential diagnosis of vascularnasal cavity lesions, particularly in the setting ofrecurrent epistaxis.

Management of Rhinosinusitis in the Settingof Endoscopic Transsphenoidal Skull BaseSurgeryMark Friedel, MD, MPH, Seth Kaplan, MD,Christopher Farrell, MD, James Evans, MD,Marc Rosen, MD, Gurston Nyquist, MDPhiladelphia, PA USA

Introduction: Endoscopic endonasal skull base surgery(ESBS) has proven to be a safe approach toselect cranial base pathologies with potential forreduced patient morbidity. Despite expandingknowledge, there remains a paucity of dataregarding management and potentialcomplications in patients undergoing ESBS withrhinosinusitis. We review our patient experienceand propose a clinical management algorithm forsurgically addressing concurrent rhinosinusitisand skull base pathology.

Methods: A retrospective chart review identified patientswho underwent both endoscopic sinus surgery(ESS) for inflammatory disease and endoscopictranssphenoidal skull base surgery at our terti-ary-care institution.

Results: 38 patients were identified. Two patients (5.2%)had a sinus mycetoma, 19/38 (50%) had chronicrhinosinusitis with nasal polyps (CRSP), and theremainder (16/38, [44.7%]) had CRS withoutnasal polyps. Four of 38 (10.5%) were stagedprocedures with ESS followed by ESBS whereas34/38 (89.5%) underwent concurrent surgery.The two patients with sinus mycetomas werestaged along with one case of medical refractorypurulent rhinosinusitis. The fourth patient wasstaged based on her preference. Six of 38(15.8%) developed post-operative sinusitisrequiring antibiotic treatment. Two patients in theconcurrent group required revision ESS forrecurrent nasal polyposis. There were no casesof intraorbital or intracranial infectiouscomplications.

Conclusions: Most cases of CRS and CRSP can be surgicallymanaged at the time of ESBS without anincreased risk of intracranial infection. Patientswith medical refractory purulent CRS or a sinusmycetoma were staged to avoid intracranialinfectious complications.

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Molecular Analysis of Bacterial FloraAssociated with Maxillary and EthmoidSinusitis Using 16s rRNA SequencingJeffrey Suh, MD, Julia Downes, M.Sc., Paula Carlson, M.Sc., Sidney Finegold, MDLos Angeles, CA USA

Introduction:The role of bacteria and infection in chronic rhi-nosinusitis remains undefined. Bacteria havepreviously been isolated from chronicallyinflamed sinuses; however, their role in thechronicity of inflammation is unknown. The pri-mary objective is to identify if the bacterial floradiffers between ipsilateral maxillary and ethmoidsinus cultures in CRS patients and controls. Thesecond objective is to compare and quantify bac-terial counts from cultures in both groups.

Methods: Specimens were obtained during surgery inpatients with CRS or controls via tissue biopsyfrom the maxillary and posterior ethmoidsinuses. Quantitative culture and identificationof organisms was performed via traditionalculture and 16s rRNA sequencing. Bacterialcolony forming units (CFU) were calculated ineach sample.

Results:In 5 control patients, the most commonly isolatedbacteria included Propionibacterium sp. withsmaller proportions of Staphylococcus speciesand a variety of anaerobic cocci. In 7 CRSpatients, facultative GNRs and Staphylococcusspecies predominated, with smaller proportionsof aerobic cocci and other bacteria. In bothgroups, no statistically significant difference(p>0.05) was found between culture sites; similarbacteria were identified from maxillary andethmoid cultures. Bacterial CFUs were higher inthe maxillary (p-0.002) and ethmoid (p=0.004)sinuses of CRS patients than in controls.

Conclusions:This study illustrates great diversity in bacterialsinus flora between patients, but also aremarkable similarity between ethmoid andmaxillary sinus cultures utilizing both standardand culture-independent techniques. Theresults suggest that more easily available andabundant ethmoid tissue obtained duringendonasal surgery is sufficient for bacterialstudies.

Mucopyocele of the Middle TurbinateMasquerading as a Nasal MassNipun Chhabra, MD, Stacey Gray, MDBoston, MA USA

Objectives:To understand a rare case of a mucopyocele ofthe concha bullosa

Study Design:Illustrative case report and review of theliterature.

Methods:An elderly gentleman's clinical and operativecourse is presented. We review the pertinentclinical and radiographic manifestations, diagno-sis, and treatment of this rare deformity of themiddle turbinate.

Results:A 76-year old man with a history of unilateralnasal obstruction and chronic sinusitis presentedafter failed topical and medical therapy.Examination revealed a disfigured and abnormalmiddle turbinate that completely occluded theright nasal fossa. Intraoperatively, a severelydistended concha bullosa over 2 cm filled withcopious purulent material was encountered.Surgical debridement and excision of the cavitywas performed and the patient symptomaticallyimproved, eventually demonstrating completeclinical resolution.

Conclusions:Although a concha bullosa is a commonanatomic variant of the middle turbinate, aliterature review revealed that infection of theconcha is very rare. In some cases, secondaryinfection and distention of the concha can extendto the orbit and even intracranially. Amucopyocele of the concha may present as aunilateral nasal mass and radiographic imagingis often necessary to further delineate the extentof obstruction. The recognition of severalimportant clinical and radiographic features canhelp aid in the diagnosis of this rare disorder.Similarly, a thorough understanding of thepathophysiology and surgical steps is essentialfor satisfactory postoperative results.


Nasal Paraganglioma: A Case ReportOmer Saglam, MD, Zuhal Saglam, MD,Fatma Uzunlar, MDBeyoglu, Istanbul Turkey

Paragangliomas are rare neuroendocrine neo-plasm of extraadrenal autonomic nervous sys-tem. These are usually benign, slowgrowing vas-cular tumors found in the abdomen, thorax, headand neck region. Head and neck paragangliomais primarily located in the temporal bone andcarotid body.

Paragangliomas of nose and paranasal sinus areextremely rare and very few cases have beenreported. In this case report we present thecase of a 25-year-old female patient with nasalparaganglioma suffering from nasal obstructionand nasal bleeding. Clinical presentation of thetumors were related to the locations. The clinicand radiological findings are not characteristics,and should be differentiating from other nasalpathologies.

Olfactory Changes After EndonasalEndoscopic Transsphenoidal Surgery forPituitary AdenomaShin Hye Kim, MD, Pona Park, MDJee Hye Wee, MD, Sung Joon Park, MD, Doo Hee Han, MD, Chae-Seo Rhee, MDSeoul, Korea

Objective: To evaluate the olfactory results after theendonasal endoscopic transsphenoidal approach(EEA) for pituitary adenoma, and to clarifypossible risk factors for poor olfactory results.

Methods: Prospective study comparing olfactory results,for patients who were admitted to our MinimallyInvasive Skull Base Center for EEA of pituitaryadenoma, was conducted. Olfactory tests wereperformed preoperatively, and 1, 3 and 6 monthsafter surgery and CT imaging was donepreoperatively and 6 month after surgery.Recovery of the olfaction was defined aspostoperative score within 75% of preoperativeresult. Various tumor factors, intraoperative andperioperative surgical findings, and postoperativeCT imaging data were analyzed for potential riskfactors.

Results: Postoperative olfaction tests showed abruptdecrease of olfaction at postoperative 1 monthand showed recovery from that point. Therewere significant differences in scores betweenrecovery and non-recovery groups. Our studyshowed 63.2% of recovery rate. In univariateanalysis, male subjects (p=0.042), with non-functioning (p=0.043) and large (p=0.006) tumor,with superior turbinectomy (p=0.034) or posteriorethmoidectomy (p=0.049) during the operationand short vertical length of septum at anteriorwall of the sphenoid sinus (p=0.032) were athigh risk of non-recovery group. However, inmultivariate analysis, only tumor size was asignificant risk factor for persistent olfactory loss(p=0.03).

Conclusion: We were able to identify the pattern of olfactorydeterioration and recovery of the olfaction afterEEA for pituitary adenoma. In addition, tumorsize larger than 2.2 cm might be considered aspoor prognostic factor for the recovery ofolfaction.


Orbital Management in Acute Invasive FungalSinusitis: A Systematic Review, Case Seriesand Evidence Based Treatment Algorithmsfor a Vexing ConundrumDevyani Lal, MD, Clifton Ewbank, MSPhoenix, AZ USA

Background: Although advances in surgical techniques andanti-fungal therapy have resulted in decreasedmorbidity and mortality from acute invasive fungalsinusitis (AIFS), management of orbital AIFSremains a dilemma. The purpose of our study wasto review our experience and the English literatureto create a contemporaneous, evidence-basedsurgical treatment algorithm for orbital AIFS.

Aims: 1. Retrospective review of orbital AIFS cases2. Systematic literature review for studies andprotocols on orbital AIFS3. Create an evidence-based surgical treatmentalgorithm

Methods: A retrospective review of all cases of orbital AIFStreated by the senior author was conducted. Asystematic review of the literature from 1985onwards was conducted. A surgical treatmentalgorithm was created.

Results: Three cases of extensive orbital AIFS involve-ment at our institution underwent serial surgicaldebridement with orbital preservation, aggressiveanti-fungal therapy and supportive management.All had fixed globes at presentation. All threepatients survived, two with intact vision. A sys-tematic literature review did not reveal any stud-ies with algorithms for orbital AIFS management.The largest series of orbital preservation wasreported in 8 patients with limited orbital involve-ment. Case reports presented both orbital exen-teration and preservation. Patients from individ-ual reports were analyzed for extent of orbitalAIFS, therapeutic interventions and survival. Asurgical treatment algorithm was created.

Conclusions: Orbital preservation may be attempted in orbitalinvolvement in AIFS. Central retinal artery occlu-sion and orbital apex syndromes may be relativeindications for exenteration. Orbit preservationmay serve cosmesis even in the setting of a non-functional eye.

Outpatient Endoscopic Sinus Surgery inCystic Fibrosis Patients - Predictive Factorsfor In-Hospital AdmissionEthan Soudry, MD, Amar Miglani, MD, Justin Chen, MD, Paul Mohabir, MD,Jayakar Nayak, MD, PhD, Peter Hwang, MDStanford, CA USA

Background:A growing number of cystic fibrosis (CF) patientsundergo endoscopic sinus surgery (ESS) in theoutpatient setting despite their CF related comor-bidities. Our objective was to determine the pre-disposing factors for post operative admission inthis unique patient group.

Methods:Retrospective chart review of cystic fibrosispatients who underwent endoscopic sinussurgery between the years 2005-2012. Multiplepreoperative, intraoperative and immediatepostoperative variables were correlated to sameday discharge versus post operative admission.

Results:33 patients who underwent 37 outpatientendoscopic sinus surgeries were identified.17/37 (46%) patients were admittedpostoperatively for observation. Surprisingly,pulmonary function, CF related comorbidities andhistory of lung transplant were not predictors ofpostoperative admission. Univariate analysisshowed that patients were more likely to beadmitted if they had a history of = 4 ESS(p=0.003), procedure duration > 2.5 hours(p=0.04), intraoperative blood loss greater than150cc (p=0.006) , increased immediate post oppain scores (p=0.004) or required larger doses ofnarcotics for pain control (p=0.015). Amaximum recovery unit pain score = 7 was theonly significant predisposing factor forpostoperative admission on logistic regressionanalysis (p=0.02).

Conclusion:Nearly half of all the CF patients in our serieswere admitted post ESS for observation.Interestingly, factors other than the CF relatedco-morbidities were associated withpostoperative admission. Understanding thesepredisposing factors for postoperative admissionmay be helpful in the perioperative planning inthis patient group undergoing ESS.


Patients Experience with In Office ConeBeam CT: A Survey StudyFariha Farid, DO, Boris Karanfilov, MDColumbus, OH USA

Introduction:The diagnosis of chronic rhinosinusitis is basedon patient symptoms, endoscopic exam andcomputed tomography (CT) findings. CT plays acritical role in defining mucosal disease andanatomic abnormalities. The gold standard forsinus imaging is multi-slice computedtomography (MSCT). Cone beam computedtomography (CBCT) was introduced for dentalimaging in the late 1990s and technologicaladvances have allowed for use in sinus imaging.The advantages of CBCT include lower radiationdose, cost savings and patient convenience.The purpose of this study is to evaluate thepatients experience with hospital based MSCTversus office based CBCT.

Methods:This was an IRB approved study conducted at atertiary rhinology practice with an accreditedCBCT. 52 patients were enrolled between July2012 and November 2012 that had undergone aMSCT within the past 3 months. Surveys werecompleted after the CBCT and consultation withthe physician. Inferential statistics determinedstatistical significance between comparisonvariables using paired sample t-test. Statisticalsignificance was evaluated at the a=0.05 level.The null hypothesis that patients have equalexperiences with CBCT versus MSCT wasrejected.

Results:Based on the variables surveyed: convenience,radiation dose, comfort, timeliness of results,accuracy and cost savings, patients responseswere statistically significant (p<0.001) in favor ofCBCT.

Conclusions:CBCT is a new technology that delivers high-quality low-radiation imaging of the sinuses.This study demonstrates that surveyed patientsreport point-of-care CBCT as a positiveexperience compared to MSCT. CBCT is a safe,efficient and cost containing imaging modality formanaging chronic rhinosinusitis.

Physician Assessment of Mucopurulence inChronic Rhinosinusitis: Inter-rater Reliabilityand Treatment ConsiderationsJorge Contreras, MD, Stella Lee, MD, Victor Yu, MD, Berrylin Ferguson, MDPittsburgh, PA USA

Introduction: No studies to date address the validity ofendoscopic assessment of the character of sino-nasal secretions in patients with mucopurulentchronic rhinosinusitis (CRS) and their associationwith a positive culture of pathogenic bacteria(PCPB). Our objective was to determine inter-rater reliability (IRR) of physician assessment ofmucopurulence in patients with CRS. Riskfactors for PCPB were also evaluated.

Methods: Thirty-eight patients with purulent CRSunderwent endoscopically guided sino-nasalcultures via aspiration and/or calginate swab.Two raters independently assessed the presenceof mucopurulence.

Results: The IRR for mucopurulence for the 38 patientswas moderate (K=0.68). However if IRR wasrestricted to the 24 patients with a PCPB, thenIRR increased (K=0.74). The assessment ofmucopurulence had a positive predictive value of76.6%, negative predictive value of 87.5%, withsensitivity of 95.8%, and low specificity of 50%for predicting a PCPB. The relative risk (RR) ofa PCPB for patients with previous endoscopicsinus surgery (ESS) was 1.58, for nasal polyps1.26, asthma 1.08, aspirin-exacerbatedrespiratory disease 0.76, and allergic rhinitis0.67. Twelve patients had immunodeficiencyand/or autoimmune disease and the majority ofPCPB for this group showed Pseudomonasaeruginosa (RR for Pseudomonas 15.34).

Conclusion: Physician assessment of mucopurulent CRSshows moderate IRR for the presence ofmucopurulence associated with a PCPB.Patients with previous ESS or nasal polyps weremore likely to have a PCPB. A history ofautoimmune or immunodeficiency disordersincreased the risk of a PCPB for Pseudomonasand could help direct appropriate choice ofantibiotic therapy.


Plasmablastic Lymphoma of the Sinus: ARare Clinical EntityJoshua Yelverton, MD, Austin DeHart, BSCeleste Powers, MD, PhD, Evan Reiter, MDRichmond, VA USA

Purpose: To present a case of plasmablastic lymphoma(PBL) of the maxillary sinus and to review theimaging, pathology, and reported treatments ofthis rare neoplasm.

Methods: Case report and literature review

Summary of Results: A 44 year old HIV-positive male presented with aone year history of recurrent, worseningepisodes of left-sided epistaxis. Physical examrevealed a mass protruding from the left middlemeatus. Computed tomography demonstrated anenhancing mass in the left maxillary sinuswithout significant bone erosion. The patientunderwent endoscopic resection. Pathologyrevealed atypical lymphoid infiltrate consistentwith PBL. PBL is most commonly described inthe oral cavity of HIV-positive patients. PBL ofthe paranasal sinuses is rare with only 15reported cases.

Conclusion: PBL should be included in the differentialdiagnosis of any HIV-positive patient whopresents with an aerodigestive tract mass. PBLhas been found to be an aggressive tumor withpoor overall survival. Response tochemotherapeutic regimens has been varied andtreatment algorithms are still being investigated.

Polypoid Changes of the Middle Turbinate asan Indicator of Atopic DiseaseLaura White, MD, Melissa Rotella, NP, John Delgaudio, MDAtlanta, GA USA

Introduction:High levels of local IgE have been demonstratedin nasal polypoid tissue; however, a consistentassociation between nasal polyps and allergyhas not been proven. The authors haveobserved that polypoid edema isolated to theleading edge of the middle turbinate (MT) ishighly associated with allergic rhinitis. Theobjective of this study was to determine if thereis an association between isolated MT polypsand inhalant allergy.

Methods: A single institution prospective study wasperformed. Consecutive patients presenting tothe senior author that were found to haveisolated MT polyps on endoscopic exam wererecruited. Nasal and allergy symptoms weredocumented on the patient's history. Allergytesting was recommended to all patients if it hadnot been performed within the past 6 months.

Results: Eighteen patients were found to have isolatedMT polypoid edema documented on endoscopicexam. Thirteen patients underwent intradermal orserum allergy testing, while five refused allergytesting of any kind. Thirteen of 13 patients whowere tested were found to be positive forinhalant allergy.

Conclusions: Our findings provide evidence to support anassociation between isolated middle turbinatepolypoid edema and inhalant allergy. Allergytesting should be recommended in patients withisolated MT polypoid edema. These findingsshould not be extrapolated to support aconnection between inhalant allergy andgeneralized polyps.

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Practice Patterns Regarding Non-invasiveSinusitis in the Immunosuppressed PatientPopulationZara Patel, MDAtlanta, GA USA

Introduction: The number of immunosuppressed patients seenin both inpatient and outpatient settings isgrowing remarkably. Currently, there is noguideline on how treatment of non-invasivesinusitis in these patients may differ from that ofthe general population, and practice patternsvary widely across the country. The purpose ofthis survey was to examine practice patterns andmanagement for this patient population.

Methods: A survey was sent to the membership list serveof the American Rhinologic Society. 12questions were asked. Four demographicquestions were asked about the physicians andtheir practices. Four questions were askedabout the type of immunocompromised patientsthey saw. Two questions were asked aboutmanagement in the setting of significant acuteand chronic sinusitis. The responses werecollected and analyzed using Pearsonindependent chi-square testing.

Results: Of the 871 members on the list serve only 89physicians responded. The majority ofresponders were sinus and skull base surgeonspracticing in an academic setting. There was alarge range of geographic location, years inpractice and patient population. Two significantfindings were relating years in practice tomanagement of chronic sinusimmunocompromised patients (p = 0.012), andthe correlation between choice of managementoption in acute and chronic sinusimmunocompromised patients (p = 0.006).

Conclusions: There is no standardized method of treating thevulnerable patient population ofimmunocompromised patients with non-invasiveacute and chronic sinusitis and this surveydemonstrates the wide range of practice.Clinical research is needed to standardize andoptimize treatment for these patients.

Prognosis for 6th Nerve Palsy Resulting fromParanasal Sinus DiseaseCraig Miller, B.S.,Vijay Ramakrishnan, MD,Oswaldo Henriquez, MD, Jeffrey Suh, MD,Alexander Chiu, MDTucson, AZ USA

Introduction:Cranial nerve VI's (CNVI) proximity to criticalvasculature and the sinuses make it susceptibleto damage leading to horizontal gaze diplopia. Awide range of literature describes myriad causesfor CNVI palsy, but there is a lack of referencesthat recognize paranasal sinus pathology as anetiology as well as the prognosis and timeline forresolution. We describe a series of patients thatpresented with CNVI palsy, their management,and prognosis for recovery.

Methods: Multi-institutional retrospective review of patientspresenting with CNVI palsy between 2009 and2012.

Results:Fourteen patients at 4 institutions were identified.Eight had neoplasms (7 malignant and 1 benign)originating from the paranasal sinuses, three hadAFS, two patients had invasive fungal sinusitisand one had chronic bacterial sinusitis.. Theaverage follow-up was 9 months (range 1-16months). Thirteen patients underwent surgery,three received chemotherapy, and four hadradiation therapy. The 6th nerve palsy resolvedin fifty percent of the cases with an average timeto resolution of six weeks (range 2 -12 weeks)

Discussion: Paranasal sinus pathology is a rare cause ofCNVI palsy. Masses compressing, but notdestroying, the neurovasculature of thecavernous sinus had optimal post-treatmentoutcomes with full resolution never occurringprior to 2 weeks from onset. Destructive lesionsthat invaded CNVI and its vasculature, ie.invasive fungus, were poor indicators forrecovery. Knowledge of factors that affectrecovery can help clinicians predict diseasecourse and prognosis for resolution of the defect.


Reinitiating CPAP after TransnasalEndoscopic Pituitary SurgeryWilliam Yao, MD, Daniel Yosher, MD, Masayoshi Takashima, MDHouston, TX USA

Objective: Examination of the possibility of restartingcontinuous positive airway pressure (CPAP) inpatients with obstructive sleep apnea (OSA)following transnasal endoscopic pituitary surgerywith cerebrospinal fluid (CSF) leak repair.

Background: Restarting CPAP for patients with OSA followingan endoscopic transnasal pituitary surgery is aconcern due to the possibility of surgical repairdisruption and pneumocephalus. There are noreferences in the literature describing the re-initiation of CPAP therapy for these patients.Delineating appropriate management protocolsfor these patients is needed since untreatedOSA can cause significant morbidity andmortality.

Method: Retrospective case series review.

Results: Two patients with severe OSA underwenttransnasal endoscopic resection of a pituitaryadenoma with primary repair of CSF leak. Inboth cases, patients had an endoscopicexamination revealing a well healed surgicalrepair. The patients were restarted on CPAP fourmonths after the repair. While collaborating withthe sleep lab, the patients were titrated to thelowest possible CPAP pressure setting. CT scanof the head obtained one week after restartingCPAP did not reveal evidence of anypneumocephalus or disruption of repair. Thepatients have continued CPAP therapy withoutany complications and with good resolution oftheir OSA symptoms.

Conclusion: This is the first reported case series describingthe safety of reinitiating CPAP therapy for OSAfollowing transnasal endoscopic pituitary surgery.As the incidence of OSA rises, appropriatemanagement algorithms for treating thesepatients become more important. This reviewwas intended to initiate further discussion on theappropriate treatment of these patients.

Relationship of Antibiotic Failure to Bacterialand Fungal Culture Results in Patients withAcute Rhinosinusitis after Endoscopic SinusSurgeryJennifer Decker, MD, Jay Dutton, MD, Neal Lofchy, MDChicago, IL USA

Introduction: The microbiology of recurrent sinusitis in patientswho have previously required sinus surgery isknown to contain resistant organisms that aredifficult to treat. Acute infection in these patientstypically requires broader-spectrum antibioticsthan in the general population. Cultures and asecond course of antibiotics are widely usedshould initial antibiotic treatment fail. However,other factors than bacterial antibiotic resistancemay play a role in treatment failure. Weexamined the bacterial types and resistancepatterns in patients with acute rhinosinusitis whofailed a first course of antibiotic therapy todetermine if bacterial resistance or other factorsinfluenced treatment outcome.

Methods: A retrospective chart review was performed ofsinus cultures over the previous 2 years in aprivate rhinology practice. Patient who hadundergone ESS, developed acute rhinosinusitis,but failed initial antibiotic therapy with availablesinus cultures taken were included. Cultureresults were reviewed for bacterial and fungalgrowth and antibiotic resistance patterns.

Results: 31% of patients failed initial antibiotics despitedocumented susceptibility of cultured bacteria totheir antibiotics. 14% of patients had resistantbacteria, 18% had fungal growth but no bacterialgrowth. 26% of patient showed no organismgrowth, and 10% of patients recovered without asecond course of oral antibiotics.

Conclusions: Failure to respond in acute infection to oralantibiotics in patients with chronic rhinosinusitisis multi-factorial in origin. Disease modifiers suchas staphylococcal superantigens, biofilms, andfungal antigens play a large role treatmentshould include both appropriate antibioticcoverage and focus on underlying inflammatorymediators.


Sinonasal Computational Fluid DynamicsAirflow Patterns in Actual and Virtual Surgeryfor Chronic RhinosinusitisGitanjali Fleischman, MD, Julia Kimbell, PhD,Dennis Frank, PhD, Charles Ebert, MD, MPH,Brent Senior, MD, Adam Zanation, MDChapel Hill, NC USA

Objective: To determine if virtual functional endoscopic sinussurgery (FESS) can be used to predict post-FESS surgical airflow patterns usingcomputational fluid dynamics (CFD).

Methods: MIMICS™ software was used to construct three-dimensional (3D) airway models based on pre-operative and 12-week post-operative CT scansof an adult patient with chronic rhinosinusitis whounderwent FESS. The pre-operative 3D modelwas then digitally modified to mimic the actualsurgery. Steady-state inspiratory airflow wassimulated using CFD software Fluent™. Airflowallocation and velocity were compared in the pre-operative, virtual surgery (VS), and post-FESSmodels.

Results: All models showed similar airflow patterns withinthe nasal cavity, excluding sinus regions. Virtualand post-FESS models showed comparableincreased airflow into the maxillary andsphenoethmoid cavities. Nasal resistances weresimilar in pre-operative and VS models (0.464and 0.455 Pa/(ml/sec), respectively), and wereover twice the resistance of post-FESS model(0.187 Pa/(ml/sec)). Total airflow into the post-FESS maxillary sinus (MS) was greater than two-fold that of the VS model.

Conclusions: Anatomical changes due to FESS did not affectairflow patterns in the nasal cavity despite thepresence of a maxillary antrostomy in both VSand post-FESS models. The VS model was ableto accurately predict post-FESS sinus airflowpatterns, but not overall nasal resistance nor theamount of total airflow into the MS. Thesedifferences may be due to effects of inferiorturbinate inflammation not accounted for in theVS model. Future directions will take intoaccount post-surgical healing, allowing us tocreate a more accurate virtual model.

Sinonasal Respiratory Epithelial AdenomatoidHamartomas: Case Series and LiteratureReviewJoseph Brunworth, MD, Rohit Garg, MD, MBA,David Keschner, MD, JD, Lester Thompson, MD,Jivianne Lee, MDAnaheim, CA USA

Background: Respiratory epithelial adenomatoid hamartomas(REAHs) are rare, benign glandular proliferations ofthe sinonasal cavity and nasopharynx. Since its ini-tial characterization; literature regarding this lesionhas been limited, mostly comprised of case reportsand histopathologic analyses.

Objectives: The aim of this study is to expand our understand-ing of this unique lesion by presenting a caseseries of REAHs.

Methods: A retrospective chart review was performed onpatients with a diagnosis of REAH from 2002-2011.Data was collected with respect to age, gender,clinical presentation, histopathology, radiographicfeatures, treatment, and outcomes. As olfactorycleft expansion has been reported to be suggestiveof REAH, maximum olfactory cleft widths(MOCs)were also determined.

Results: 51 cases of REAH were identified, 37 males(72.5%) and 14 females(27.5%). The mean agewas 58.4 years. Headache, nasal obstruction,rhinorrhea, and hyposmia were the most commonpresenting symptoms. 16(31.4%) presented asisolated lesions of the nasal cavity, while 35(68.6%) were associated with concurrentinflammatory pathology. Enlargement of MOCswas evident on computed tomography(CT), withmean MOCs of 8.64mm and 9.4mm in thecoronal/axial planes respectively. There were nostatistically significant differences between MOCsof isolated (7.96mm) versus associated (9.63mm)lesions (p=0.25). All patients underwentendoscopic resection with no recurrences after amean follow-up of 27.2 months.

Conclusion: REAHs are rare entities that should be includedin the differential diagnosis of sinonasal masses.Clinically, they may appear as localized, isolatedlesions or occur more diffusely in conjunction withother inflammatory processes. Irrespective ofclinical presentation, endoscopic removal appearsto be curative.


Sinonasal Sarcoidosis: A New System ofClassification Acting as a Guide to Diagnosisand TreatmentWilliam Lawson, MD, DDS, Nancy Jiang, MD, Jeffrey Cheng, MDNew York, NY USA

Objectives: The signs and symptoms of sinonasalsarcoidosis are diverse and non-specific. Iteasily mimics more common sinonasal disorderssuch as allergic rhinitis, bacterial sinusitis, andatrophic rhinitis. The purpose of this study is todevelop a classification system that will helpserve as a guide for both diagnosis andtreatment.

Study Design: case series and review of the literature

Methods: A retrospective chart review was performed of allpatients with biopsy proven sinonasal sarcoidosistreated by the senior author from 1974 to 2009.A PubMed literature review of all published caseseries of sinonasal sarcoidosis was alsoreviewed.

Results: The charts of 14 patients were reviewed. Followup time ranged from 6 months to 28 years.Presenting signs included hypertrophic mucosa,nasal polyps, crusting, nasal enlargement, anddestructive processes. Eight patients underwentmedical management alone and 6 patientsunderwent endoscopic sinus surgery. Four outof the 6 patients were successfully treated withsurgery. On review of the literature, 218 casesof of sinonasal sarcoidosis was found, of which39 patients underwent surgery and clinicalimprovement was seen in 12 of these patients.

Conclusions: Based on critical analysis of the clinicalpresentation in our case series and on review ofthe literature, sinonasal sarcoidosis can beclassified into 4 subgroups: atrophic, mucosalhypertrophic, destructive, and nasalenlargement. Each subgroup respondsdifferently to treatment and has its owndifferential diagnosis. Surgery is only indicatedfor a select group of patients and the vastmajority of patients benefit from medicalmanagement alone.

Small Colony Variants of StaphylococcusAureus in Chronic RhinosinusitisSarah Gitomer, MSIV, Daniel Frank, PhD, Vijay Ramakrishnan, MDAurora, CO USA

Introduction: S. aureus is a prevalent pathogen in chronicrhinosinusitis (CRS), but is difficult to eradicateand often recurs after treatment. Small colonyvariants (SCVs) are a metabolically inactive formof bacteria that can live intramucosally and areresistant to antibiotics. In order to determinewhether SCVs contribute to S. aureus's ability topersist after standard treatments we comparedthe prevalence of S. aureus SCVs in CRSpatients and controls.

Methods:Sinus aspirates and endoscopically-guidedswabs were collected and plated on grampositive-(CNA) and Staphylococcus-specific(mannitol) media and screened for the presenceof phenotypically small colonies. SCVs' specieswere determined with genetic techniques.

Results: Thirty-five samples were collected, 22 from CRSpatients and 13 from control patients. FourteenCRS patient samples grew S. aureus (63.6%),and of the S. aureus positive samples, 2 grewSCVs (9.1%), neither of which was confirmed tobe S. aureus with genetic sequencing. Of thecontrols, 9 grew S. aureus (69.2%), and ofthese, 2 grew SCVs (15.4%), neither of whichwas S. aureus. Significantly more SCVs grew inthe control group than in the CRS group(p<0.01). On average follow-up of 1.9 months,the SCV-positive patients did not develop newsymptoms of CRS.

Conclusions: Despite rigorous screening, neither CRS orcontrol populations were found to be colonizedwith S. aureus SCVs. Because SCVs were morecommonly associated with control patients andnot correlated with recurrence of symptoms, weconclude that they are unlikely to be a commoncause of recurrence of CRS symptoms.

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Surgical Management Of Rhinosinusitis inOnco-Haematological PatientsStefano Di Girolamo, MD, Sara Mazzone, MD,Roberta Di Mauro, Md, Maria Cantonetti, MDRome, Italy

Introduction: Paranasal sinus infection in immunocompro-mised patients demands a combination of med-ical and surgical therapy. Multiple medical prob-lems put the surgeon in a challenging choise.The sinus ostia blockage plays a key role in thepathogenesis of the sinus infections. Balloondilatation surgery (DS), a complementary tool forendoscopic sinus surgery, is a minimally inva-sive, tissue preserving procedure. The studyevaluate the results of this treatment for isolatedsinusitis in severe immunocompromised patients.

Materials and Methods:A retrospective chart review was conducted in110 patients affected by rhinosinusitis selected ina group of 380 haematologic patients. 25patients were treated with DS, in 17 wasrequired general anesthesia and in 8 has beenused a local anesthetic. The other 85 patientswere treated with traditional endoscopic sinussurgery (ESS), 70 with general anesthesia and15 with local anesthesia.

Results: In DS group the intraoperative bloodloss wasminimum. A lower number of anterior nasalpacking and repacking were necessary. Post-surgical nasal debriments and the incidence ofcrusting and synechiae were lower. Localanesthesia was possible in a larger grouppatients.

Conclusions: A careful balance between surgery and medicaltherapy is mandatory to provide the righttreatment for these patients that are often poorsurgical candidates. Balloon dilatation surgeryrepresents a potentially low aggressive treatmentand appears to be relatively safe and effective inonco-hematologic patients. All these remarksmay lead the surgeon to consider a largernumber candidates for surgical procedure.

The Diagnosis and Management of SinonasalGlomangiopericytomaBenjamin Paul, MD, Jonathan Lebowitz, Aron Pollack, MD, Richard Lebowitz, MDNew York, NY USA

Introduction:The following is a case presentation of a 61 yearold male who was referred to the otolaryngologyclinic with epistaxis and was found to have alarge unilateral nasal mass. After a transnasalendoscopic excision, the lesion was diagnosedas a rare, recently reclassified sinonasalneoplasm termed a glomangiopericytoma.

Discussion:Previously described as a sinonasal-type heman-giopericytoma, an endonasal glomangiopericy-toma has been renamed because of its uniquehistologic subtype, a perivascular glomus-likemyoid phenotype, and distinct clinical behaviorwhen compared with other soft tissue head andneck hemangiopericytomas. Overall, gloman-giopericytoma carries a good prognosis after sur-gical resection as they are indolent with lowmalignant potential.

Summary:The following case report highlights the challeng-ing histologic differential diagnosis and discussesof the management of a glomangiopericytomawhen the mitotic division rate is unexpectedlyhigh.


The Impact of Preoperative SystemicAntibiotics and Steroids on SurgicalOutcomes in CRS Patients Undergoing FESS:A Retrospective StudyJamil Manji, BSc.H, Andrew Thamboo, MD, Al-Rahim Habib, BSc, Iain Hathorn, MD, Amin Javer, MD FRCSC FARSVancouver, BC Canada

Background: The highly vascularized nature of the paranasalsinuses makes intraoperative blood loss asignificant variable for functional endoscopicsinus surgery (FESS). Bleeding into theendoscopic field of view during FESS representsa hindrance to the surgeon and can increase thechance of complications. Several options havebeen suggested for controlling intraoperativeblood loss such as local vasoconstrictors, patientbody position, and preoperative corticosteroidtreatment.

Objective: Our objective was to retrospectively assess theimpact of systemic preoperative antibiotics andcorticosteroids on surgical outcomes in patientsundergoing FESS for CRS.

Methods: A retrospective chart review of 106 patients thathad undergone bilateral FESS was conducted.This population consisted of patients that hadreceived the standard of care course of Clavulinand Prednisone for 7 days preoperatively (n=53),and those that had not because they wereparticipants in an unrelated randomized controltrial (n=53). Time of surgery (TOS) was theprimary outcome measure. Total blood loss(TBL) and blood loss per minute (BL/min) werealso recorded.

Results: TOS was significantly reduced in the groupreceiving preoperative medication (p=0.0279).However, TBL (p=0.2413) and BL/min(p=0.6452) were not significantly differentbetween the two groups. Population stratificationby disease severity produced similar results as inthe overall population.

Conclusions:While we found no significant impact on blood

loss; preoperative treatment with systemicantibiotics and steroids may facilitate the ease ofFESS cases, as indicated by a significantdecrease in duration of surgery.

The Inferiorly Based Septal TranspositionFlap for Coverage of Large Nasal FloorMucosal DefectsJonathan Ting, MD, Nipun Chhabra, MD, ArthurWu, MD, Benjamin Bleier, MDIndianapolis, Indiana USA

Introduction: To achieve coverage of massive skull basedefects, nasoseptal flap harvest may includeportions of the nasal floor and inferior meatalmucosa. Exposure of large areas of bone mayresult in prolonged wound healing andsymptomatic nasal crusting. This study describesa novel inferiorly based, contralateral septaltransposition flap designed to provideintraoperative mucosal coverage for theseregions.

Methods: A morphometric analysis of the septum, nasalfloor, and inferior meatus was performed in 10multiplanar high-resolution sinus CT scans.Dimensions of the transposition flap required forcoverage of the contralateral inferior meatuswere calculated and correlated with relevantanatomic landmarks. A review of all cases inwhich a transposition flap was utilized wasperformed.

Results:The average height of the transposition flap andwidth of the contralateral nasal floor defect were3.3cm and 1.24cm respectively. In all 10 CTscans, the projected placement of a transpositionflap across a midline septal defect resulted incoverage of the nasal floor laterally into theinferior meatus, as long as the inferior border ofthe septectomy was ~1cm from the nasal floor.Three patients underwent a transposition flapfollowing posterior septectomy and extendednasoseptal flap harvest with good results.

Conclusions:The expansive mucosal harvest required in thesetting of large defects results in extensive areasof demucosalized bone along the nasal floor andinferior meatus. When coupled with a judiciousposterior septectomy, the described septaltransposition flap can be used to minimize anysignificant bone exposure following surgery.


The Pedicled Nasoseptal Flap in theEndoscopic Closure of Idiopathic ClivalCerebrospinal Fluid LeaksAlessandro Pusateri, MD, Enzo Emanuelli, MD,Elina Matti, MD, Davide Locatelli, MD, Frank Rikki Canevari, MD, Fabio Pagella, MDPavia, Italy

Introduction: Cerebrospinal fluid (CSF) leaks that originatewithin the posterior wall of the sphenoid sinus(clivus) pose a surgical challenge due todifficulties with access and visualization. Theobjective of this report is to illustrate concepts forthe successful management of idiopathic clivalCSF leaks.

Methods: A retrospective data analysis was performed on8 patients who presented to our departments forendoscopic repair of a spontaneous clival CSFleak from 2005 to 2012. A layered reconstructionof the posterior sphenoid sinus wall underendoscopic visualization was performed. GroupA (n = 5) received a standard skull base repairwith a multilayered reconstruction (underlay andoverlay grafting), Group B (n = 3) instead,underwent a single-layered (overlay grafting)reconstruction using a pedicled nasoseptal flap(Hadad flap).

Results: The patient cohort included 8 women, mean agewas 63 years (36 - 91 years). An endoscopictransnasal paraseptal approach was performedin 2 cases (25%), a transethmoidal approach in6 cases (75%). The average hospital stay was6.5 days (4 - 12 days). The mean length offollow-up was 49 months (6 - 95 months). Theoverall success of the endoscopic repair was87.5% (7/8). Group A / Group B: 80% (4/5) /100% (3/3).

Conclusions: This series demonstrates that a minimallyinvasive endoscopic repair of idiopathic clivalCSF leaks may be accomplished with anacceptable rate of morbidity and excellentoutcomes, even with a single-layeredreconstruction of the defect using a pediclednasoseptal flap.

The Positive Predictive Value of RadiologicImaging of Clival LesionsAkaber Halawi, MD, Myriam Bermudez, MD,Bruce Tan, MD, Rackesh Chandra, MD, Robert Kern, MD, David Conley, MDChicago, IL USA

Introduction:Clival lesions represent a heterogeneous groupof pathologies often sharing overlappingradiographic features posing a dilemma inaccurate pre-operative diagnosis. The objectiveof this analysis is to assess the positivepredictive value of radiologic evaluations of clivallesions.

Methods:Retrospective chart review of endoscopicallyresected clival lesions from 2006 to 2012.

Results:33 patients were identified. Mean age was 49.7.Ten patients had a histologic diagnosis ofchordoma ,2 possible low gradechondrosarcomas, 4 craniopharyngiomasextending to the clivus, 2 clival pituitaryadenomas, 1 ecchordosis physaliphora, 1epidermoid, 1 cholesterol granuloma, 1meningioma, 3 metastatic carcinomas, 1squamous cell carcinoma, 1 Burkitt's Lymphoma,1 pituicytoma, and 1 rhabdoid papillary. Threechordoma patients were excluded for incompleteimaging. The PPV for radiologic diagnosis ofchordomas was 70%; it increases to 76.92%when the radiologic impression includeschordomas and low grade chondrosarcoma . ThePPV for malignant lesions was 50%. The PPVfor craniopharyngiomas was 100%. 42.9% ofpatients with chordomas were localized to theclivus, 69.2% were hypointense on T1, 76.9%were hyperintense on T2, varying degree ofenhancement(53% showed more than 90%homogenous enhancement), 61% had non-restricted DWI, and 76.9% had cortical disruptionon CT scan.

Conclusion:Although chordomas are the most common clivallesion, other pathologies including malignancycomprise 63.6 % of lesions in this area. Themost reliable radiologic features of chordoma arehyperintense T2 signal on MRI, corticaldisruption on CT, and location. Radiographicstudies have a high but imperfect PPV for thiscommon clival lesion.


The Prevalence of Uncinate Process Osteitisin CRS Patients Versus ControlsPeter Catalano, MD, Meir Warman, MD, Rahul Gupta, MD, Rohan Wijewickrama, MDBoston, MA USA

Background: Chronic rhinosinusitis (CRS) is a commoninflammatory condition with varied etiologies.Osteitis of the underlying bone and in particularthe uncinate process (UP) is postulated as oneof the main causes for CRS. The prevalence ofbone remodeling changes in the uncinateprocess (UP) of healthy controls has not beenpreviously examined, therefore this study wasconducted to determine and compare theprevalence of osteitis of the uncinate bone inpatients with CRS versus healthy controls.

Methods: Prospective histopathologic examination for thepresence or absence of osteitis of theUP/uncinate bone was performed in the studygroup (patients undergoing sinus surgery forCRS) and a similar-sized control group. Thepresence of osteitis was determined as boneremodeling and the formation of woven boneusing polarized light microscopy.

Results: A total of 20 uncinate bones were examined: 10from patients with CRS and 10 controls. Meanage of patients was 43 and 44 years in the twogroups. Pathologic evidence of osteitis wasfound in 50% of the CRS patients and in 30% ofthe control group.

Conclusions: Osteitis of the uncinate bone is present in bothasymptomatic control patients as well as thoseundergoing surgery for CRS. These resultsquestion the contribution of UP osteitis as asignificant factor in the pathogenesis of CRS.This preliminary data needs to be furtherevaluated in large-scale CRS and healthypopulations.

The Relationship of the Natural SphenoidOstium to the Skull BaseAkaber Halawi, MD, Patrick Simon, MD, Alcina Lidder, MD, Rackesh Chandra, MDChicago, IL USA

Introduction: Various intranasal landmarks have beendescribed to aid in localization of the naturalsphenoid sinus ostium. The objective of thisstudy is to identify the ostium location relative tothe skull base, and to assess relationshipsbetween ostium location and either sphenoiddisease or pneumatization pattern.

Methods: 202 consecutive Xoran Mini-CAT scans ofpatients with no prior history of sinus surgerywere evaluated. The natural sphenoid ostiumwas identified in axial, coronal, and sagittalplanes. Distances from the planum to the ostiumand from the planum to the sinus floor werecalculated. Lund-Mackay score andpneumatization pattern were recorded for eachsphenoid sinus.

Results: Mean distance from planum to ostium was 11.2+/- 2.8mm (range 4.4-19.2mm). This, onaverage, encompassed 46.5 +/- 11% of the totalsphenoid height. ANOVA with post hoc Tukeyanalysis revealed that the ostium was closer tothe planum in sinuses with sellar (p=0.02) orpresellar (p=0.009) pneumatization, compared tothose where pneumatization was postsellar.Although asymmetry was observed in somepatients, the ostium tended to be in a similarposition on each side. There was no significantrelationship between ostium location and degreeof sinus disease.

Conclusions: The natural ostium of the sphenoid sinus, onaverage, is located at the midpoint of thesphenoid face. However, significant variabilitybetween patients can be observed. Surgeonsshould also recognize that the ostium may becloser to the skull base when the sinus is lesspneumatized.


The Role of Allergic Rhinitis and Age asPotential Risk Factors for OrbitalComplications of Rhinosinusitis in Children:Our ExperienceAlessandro Pusateri, MD, Elina Matti, MD,Gian Luigi Marseglia, MD, Ilaria Brambilla, MD,Michele Caputo, MD, Fabio Pagella, MDPavia, Italy

Introduction: The purpose of this report is to determineallergic rhinitis (AR) and age as potential riskfactors for the development of orbitalcomplications of rhinosinusitis in children.

Methods: We included in the present study 72 patientspresenting to our departments with a diagnosisof rhinosinusitis with orbital complications, from2005 until 2011. All patients were investigated byflexible nasal endoscopy as well as forunderlying AR. Computed tomography (CT) wasobtained only in selected cases.

Results: They were grouped according with Chandler'sclassification: Preseptal cellulitis was diagnosedin 45 patients (62.5%); orbital cellulitis in 25(34.7%); an orbital subperiosteal abscess in 2(2.8%). No orbital abscess or cavernous sinusthrombosis were found. In 26 (36.1%) of the 72patients an accurate allergy evaluation wasperformed with skin prick testing. AR was foundin 7 (53.8%) of 13 children with preseptalcellulitis, in 2 (18.2%) out of 11 with orbitalcellulitis, and in 1 (50%) out of 2 withsubperiosteal abscess. The prevalence of ARwas higher in patients presenting in pollenseason from March to August (8:17) than inpatients presenting between September andFebruary (2:9).

Conclusions: AR could be considered a possible cofactor inthe pathogenesis of orbital complications ofrhinosinusitis in children. Moreover, according toour population, age only influences the type oforbital complication and not the incidence. Infact, in our series, older children are more likelyto develop subperiosteal abscess (mean age 7years), whereas younger children developpreseptal cellulitis (mean age 4.8 years).

Tilt CT Image Reconstruction and Analysis inAssessment of Frontal Sinus OutflowAllison Fry, BS, Wade Han, MDOrlando, FL USA

Assessment of frontal sinus outflow and itsobstruction is critical during diagnosis andpreoperative planning for frontal sinus surgery.Understanding frontal drainage pathway withstandard orthogonal triplannar (coronal, axial andsagittal) analysis is challenging because ofanatomical variability, inconsistent imagingtechniques and oblique nature of the pathway.We hypothesize by tracing the frontal sinusoutflow through the inferior frontal and anteriorsuperior ethmoid region, in a plane perpendicularto the outflow pathway, will provide the mostvisually intuitive understanding of its torturouscourse amongst various high frontoethmoid cells.This plane will allow surgeons to pinpoint wherethe outflow obstruction occurs and determinewhich frontoethmoid cells contribute to thenarrowing. In addition, the dimensions andshapes of various relevant anterior ethmoid cellssurrounding the outflow pathway can be studied.Cephalometric landmarks are used to achieve aconsistent tilt angle where the frontal outflowtract is readily visualized. The tilt angles in 49consecutive patients undergoing routinemaxillofacial CT studies are statisticallyanalyzed. The plane through Nasion and bilateralOrbitale is noted to be the most consistent anduseful in studying frontal outflow pathway. Itranges from 20-36 degrees with an average of27 degrees in relation to the hard palate. The CTimage sets in this tilt plane from frontal sinus roofto frontal outflow exit in middle meatus orinfundibulum are studied; frontal outflowanatomical findings are recorded and tabulated.Frontal outflow exit anatomy on CT at superiormiddle meatus/infundibulum is compared with 70degree rigid middle meatal endoscopicexamination.

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Turbinate Reduction Using the TurbinateSculpting MethodCharles Hurbis, MDCoos Bay, OR USA

Intro: Finding the best method of inferior turbinatereduction continues to be an ongoing process.Options include complete or partial reductions byway of various thermal shrinkage techniques,direct mucosal removal or stroma reductions.Control of the end result can be troublesomesince there are large patient to patient variationsin anatomy and mucosal make-up. The methodthat I have found most consistent in correctinginferior turbinate hypertrophy is a preciseturbinate sculpting technique which will bedescribed and demonstrated.

Methods: For this study ten patients were enrolled andtreated for turbinate hypertrophy by the sculptingtechnique. Turbinates were addressed andtreated in thirds. Pre, intra and post-operativephotos of the airways were documented.Procedural videos were taken for demonstrationpurposes. Treatment success was based on theNOSE scale subjective responses and acousticrhinomanometry measurements.

Results: All of the patients achieved dramaticimprovements in their nasal airways bothsubjectively and objectively measured at 4+weeks after their surgery. We did not encounterany issues with unusual intra or post-operativebleeding. There were no complications.

Conclusions: The turbinate sculpting method has allowed us toachieve consistent improvement in our patientswith turbinate hypertrophy. This methodproduces an accurate, uniform reduction of theturbinates, regardless of patient to patientvariations in nasal anatomy or mucosal type. Itis also a safe technique which allows formaximal safe effect with less chance of overreduction.

Typical Carcinoid Nasopharyngeal Tumor:Highlights of a Unique CaseMathieu Bergeron, MD, B.Pharm, Sylvie Nadeau, MDQuebec, Quebec Canada

Objective:Carcinoid tumors are rare, particularly in thehead and neck region. The first case of primarywell-differentiated carcinoid tumor arising fromthe nasopharynx was documented in 2009 byWarman et al and treated by combined externalbeam radiation and cold somatostatin analogue.No case of this unique type of lesion had beensuccessfully treated with surgery alone until now.

The Case:A 68 year-old previously healthy woman wasreferred to our tertiary care center for long-termunilateral nasal congestion of unknown etiology.Upon rigid sinusoscopy exam, a right-sidednasopharynx pedunculated mass close to theRosenmüller's fossa was visualized. Anenhanced MRI showed a nasopharyngeal masswith an isointense nasopharyngeal lesion on T2-weighted involving superior right-sided nasalcavity. Biopsy was highly suspicious of a typicalcarcinoid. This was confirmed on both themorphologic and immunologic exams. The lesionwas successfully removed with transnasalendoscopic surgery with negative margins. Sixweeks after the surgery, the patient underwentan octreotide scintigraphy, which was normal.

Conclusion:To our knowledge, this was the first casesuccessfully treated and cured with endoscopicsurgery alone. In case of localized typicalcarcinoid tumors, negative margins at the time ofthe surgery and a negative octreotidescintigraphy don't require any other modality oftreatment. Periodic follow-ups with completehead and neck exam.


Utility of Three Dimensional CT Reformattingof the Skull Base as and Aid to SurgicalPlanningAaron Fletcher, MD, Jeremy Greenlee, MD, Erin O'Brien, MD, Scott Graham, MD,Eugene Chang, MDIowa City, IA USA

Introduction: Pre-operative identification of skull base defectsis central to the planning and success ofendoscopic repair. As high-resolution computedtomography (CT) imaging technology hasprogressed, the subsequent number of 2-dimensional images has increased. The burdenof 3-dimensional interpretation of these imageshas fallen to the surgeon. Our objective is todevelop a 3-d computer-generated model toassist surgeons in identifying skull base defects.

Study design: Retrospective case series of three patients whohad undergone endoscopic repair of anteriorskull base defects.

Methods: We utilized Amira, a software platform to convert2-d CT images to a 3-d model segmented intoskull, brain, and soft tissue windows to quantifythe size of the skull base defect. Our findingswere validated by a neuroradiologistinterpretation of the 2-d images.

Results: We successfully developed a segmented 3-dmodel of the skull base in approximately 15minutes time from the 2-d images. This modelenabled visualization of the skull base defectfrom various perspectives, including anendoscopic as well as top-down approach.Quantification of the size and location of thedefect were similar between the 3-d model andthe 2-d CT findings.

Conclusions: 3-d computer models of the skull base enablethe surgeon a unique perspective in thepreoperative planning of skull base defect repair.With practice, this technique is accurate andefficient and may assist in the analysis of skullbase defects.

Validation of a Novel Device for NasalParticulate Delivery: A Pilot StudyKhalili Sammy, MD, Brian Rotenberg, MD MPHLondon, Ontario Canada

Introduction: Intranasal medication delivery for chronicrhinosinusitis or allergic rhinitis is considered amainstay of therapy but is hampered by poorcompliance. Amongst reasons given are theunpleasant sensations associated with spraypenetration into the naso- or oro-pharynx. Ourobjective was to validate a novel method ofparticle delivery to the nose that would abrogatethese issues.

Methodology:Subjects who met study criteria underwent

intranasal particle delivery using a novel device(Trivair Nasal Deposition System, TrimelPharmaceuticals, Toronto) that deliveredanhydrous lactose particles into the nose via atransoral air puff (thus elevating soft palate andblocking the nasopharynx). Subjects had theirnostrils randomized into four groups (particle size5 micron and 50 micron versus dose 12.5mg and25mg). Using a high-definition endoscopicphotography, particle deposition was assessed at1 minute, 10 minutes and 30 minutes on theinferior turbinate, middle turbinate, andnasopharynx respectively. Each image wascompared using an expert 2-person panel forpercentage particles remaining. Non-parametricdata was assessed using Strata software using aWilcoxin sign-rank test.

Results: Twelve nostrils in total met study criteria. Theresults showed no difference in effectiveness ofnasal particle retention between the groupsbased on particle size or dose. No particlesentered the naso- or oro-pharynx. There were nostatistical differences between the groups.

Conclusion: This study provides proof-of-principle evidencethat the Trivair Nasal Deposition System iseffective at retaining medication in the nosewithout pharyngeal penetration. This providesspringboard evidence to move forward withlarger studies on this device.


Vibratory Energy Applied to Facial SoftTissue to Alleviate Pain during NasalInstrumentationsAllison Fry, BS, Wade Han, MDOrlando, FL USA

Despite adequate topical anesthesia, nasalinstrumentations including routinenasoendoscopy and fiberoptic laryngoscopy mayinvolve a considerable amount of pain anddiscomfort when nasal mucus membrane istouched in patients who are awake. ClassicMelzack-Wall Gate theory of Pain suggestssimultaneous stimulation of larger non-noxioussurface nerve endings may alleviate perceivedpain from smaller nasal cavity nerve endingsduring intranasal manipulation. We hypothesize,vibratory energy applied transcutaneously tosupraorbital and supratrochlear nerves, branchesof the larger frontal nerve (V1), may alleviatepainful stimuli of the smaller intranasal anteriorand posterior ethmoid branches of nasociliarynerve. In maxillary (V2) distribution, vibratoryenergy applied to the larger infraorbital nerve,through facial soft tissue, may alleviate pain ofsmaller branches of palatine and superioralveolar nerves intranasally. A pilot study of 30patients undergoing in office fiberopticlaryngoscopy or deep middle meatalnasoendoscopy was conducted. Vibratory energywas applied to infraorbital and supraorbitalregions respectively when mucosa contact isunavoidable and pain is verbalized by thepatient. Subjective pain scores rated on Wong-Baker scale of 1-10 by the patient, before andafter the vibratory application, were recorded.The pain scores from a control cohort of 30patients undergoing the same intranasalinstrumentation, without external pain alleviator,were obtained and compared. This preliminarystudy shows that transcutaneous vibratoryenergy application, over larger terminal branchesof trigeminal V1 and V2, alleviates painperception during in office intranasal ortransnasal instrumentations.

Volumetric Analysis of the Paranasal Sinusesin Patients with Cystic FibrosisWinslo Idicula, MD, Stanley McClurg, MD,Stephen Kirkby, MD, Meredith Merz, MDColumbus, OH USA

Objective:The objective of this study is to use a newvolumetric analysis technique to compare theparanasal sinus volumes, as seen on CT scan,of adult Cystic Fibrosis patients to those ofnormal adult controls. We hypothesize that thesinus volumes will be significantly smaller inpatients than in controls.

Study Design: Retrospective Pilot Study

Methods: The Terarecon 3D system will be used tocalculate the volumes of the maxillary, frontal,and sphenoid sinuses on CT scans in ten adultpatients with Cystic Fibrosis and compare themto ten adult controls. This system uses theHounsfield unit of air within each sinus tocompute the volume of the specified spaces in athree dimensional format. These findings willalso be correlated to the Lund-Mackay scoringsystem.

Results: We will demonstrate the method of the Terarecon3D system in analyzing sinus volumes. We willreport the volumes of the sinuses in our CysticFibrosis patient population and the controlpopulation. Additionally, we will use this pilotdata to determine if a study with a larger samplesize is indicated and to determine whether thedegree of hypoplasia predicts the severity ofsymptoms or frequency of surgery.

Discussion: There is evidence to suggest that patients withcystic fibrosis have hypoplasia of the sinuses. Iftrue, this could also contribute to the propensityto sinus disease in this population. Sinushypoplasia should be recognized as it hassignificant surgical ramifications and increasesthe likelihood of certain complications, includingorbital injury.



59th Annual Meeting of the ARSwww.american-rhinologic.org/annual_meeting

Guest Countries: Australia, China, New Zealand and South KoreaSeptember 28, 2013* Hyatt Regency Vancouver, Vancouver, Canada*One day prior to AAO-HNS Mtg

Abstract Deadline: June 10, 2013 Manuscript Deadline: Aug. 26, 2013

Program Highlights:Panel: What is Happening in the World of Rhinology: An International Forum of Allergy & RhinologyPanel: An Insightful Discussion: In hindsight, I would have handled this differently. Lessons learned the hard way… The 9th Annual Kennedy Lecture: Berrylin J. Ferguson, MD: Twenty-five Years of Sinus Study: learning and unlearningShowcasing ARS Research and the International Forum of Allergy and RhinologyARS/AAOA Combined Panel: Changing Your Practice: Strategies to Manage Your Patients with Recalcitrant Rhinosinusitis

Join your colleagues to discuss the latest advances in our field and discuss your challenging cases!

For further information, please contact Wendi Perez, ARS Administrator, American Rhinologic Society, PO Box 495, Warwick, NY 10990Tel: 845.988.1631 • Fax: 845.986.1527 • [email protected]

www.american-rhinologic.org

September 28, 2013Hyatt Regency Vancouver, Vancouver, Canada

59th annual meeting

Documents

ARS COSM 2-2013d - American Rhinologic