58 annual meeting - american rhinologic... 3 presidential welcome to the 58th annual ars meeting on...

58th

annual meetingof the American Rhinologic Society

September 8, 2012Grand Hyatt Washington, Washington, DC

58th

annual meetingof the American Rhinologic SocietySeptember 8, 2012

Welcome to our Guest Countries...

France

Japan

South Africa

3www.american-rhinologic.org

Presidential Welcome to the 58th Annual ARS Meeting

On behalf of the Board of Directors of the American Rhinologic Society, it is anhonor to welcome you to the 58th Annual ARS Meeting. What could possibly bemore important than to sit back and relax in the comfort of the Washington GrandHyatt here in our nation's capital two months prior to the general election.

I want to thank our Program Chair, Todd Kingdom and the Program Committee forputting together a truly outstanding meeting. During this conference attendees willhave the opportunity to hear leading experts in Rhinology and Skull base surgery.The latest research opportunities will be presented, pros and cons will be debatedduring panel discussions and special topics of interest will be delivered by invitedkey note speakers.

Highlights include:• Dissection Demonstration from the podium by Professor Heinz Stammberger:• 8th Annual David W. Kennedy Lectureship by Donald C. Lanza, MD• Breakfast Symposium: “New Innovations in Rhinology. The Hottest Topics with

Breakfast”• Residents and fellows in training luncheon • Poster Presentation Wine & Cheese Reception• Guest Countries for 2012 will be South Africa, France and Japan

This conference will provide an opportunity to meet with old friends and colleaguesand build or renew relationships.

To our residents and fellows and first time attendees I welcome you all to thismeeting and hope the stimulation is such that you will join the ARS.This meeting is designed to stimulate the interests of both academic and communitybased rhinologists and otolaryngologists. Please visit with our Exhibitors, see theirlatest products and thank them for their support.

A special thank you to Wendi Perez, ARS administrator and her team for their hardwork and effort in putting together this meeting.

Please help me make this meeting a memorable one and enjoy your stay here inWashington, DC.

Michael Setzen MD, FACSPresident, American Rhinologic Society

Michael Setzen, MD

4 American Rhinologic Society

Program Chair Welcome Welcome to the 58th Annual Meeting of ARS

I would like to welcome you to the 58th Annual Meeting of the AmericanRhinologic Society in Washington, DC. Once again the ARS is proud toprovide this educational program to serve our members, all otolaryngologists,and allied health care providers from throughout the United States, NorthAmerica, and the world.

This year the program structure will include a morning Plenary Session followedby two afternoon scientific sessions entitled Clinical Rhinology and Basic &Translational Research.

The morning session will feature the 8th Annual Kennedy Lecture delivered byDr. Donald Lanza, past ARS President and leader in the our field. A clinicalpanel on avoiding complications in ESS and a discussion of challenges inrhinology will be led by experts in rhinology. For the first time we will have alive cadaver demonstration dissection performed by Professor HeinzStammberger.

The afternoon sessions will feature 40 scientific oral abstract presentationsselected from over 100 submissions. Nearly 60 scientific poster presentationswill be on display for review.

In addition there will be two afternoon panels featuring expert discussion on theChanging Views on the Contributions of Microbes in CRS and Entopy: LocalIgE Production in Sinonasal Disease.

It is my sincere hope that there is “something” in this program for everyattendee. Thank you for your attendance and your support of the AmericanRhinologic Society.

Todd T. Kingdom, MDARS President-elect & Program Chair

Todd Kingdom, MD


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

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

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

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

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

Timothy Smith, MDFirst Vice PresidentOregon Health and Science UniversityOregon Sinus Center3181 SW Sam Jackson Park Rd PV- 01Portland, OR 97239Tel: (503) 494-7413Fax: (503) 494-4631Email: [email protected]

Roy Casiano, MDSecond Vice PresidentUniversity of Miami Hospitals & Clinics1120 NW 14th Street5th floor, Clinical Research BldgMiami, FL 33136

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

American Rhinologic Society Executives - 2012


ARS Board of Directors

Consultants to the Board

Pete Batra, MD Robert Kern, MD

Richard Orlandi, MD James Palmer, MD

Christopher Melroy, MD

Ralph Metson, MD

John DelGaudio, MD

Rodney Schlosser, MD

Marc Dubin, MD

Michael Stewart, MD


Chairs

Audit Subinoy Das, MD

By-LawsDouglas Reh, MD

Development SteeringJoe Jacobs, MD

CMERaj Sindwani, MD

EthicsMark Zacharek, MD

Information TechnologyKevin Welch, MD

International LiaisonNicholas Busaba, MD

Patient AdvocacyJivianne Lee, MD

Pediatric RhinologySanjay Parikh, MD

NewsletterMarc Dubin, MD

EducationJoseph Han, MD

AwardsDavid Poetker, MD

FellowshipTodd Kingdom, MD

MembershipStephanie Joe, MD

Resident/FellowsBellachew Tessema, MD

Research CommitteeAndrew Lane, 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, MD*Deceased

Past Presidents Past Secretaries2009-Present 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 (ARS) is accredited by the Accreditation Council for ContinuingMedical Education to provide continuing medical education for physicians.

Credit Designation StatementThe ARS designates this live activity for a maximum of 7.50 AMA PRA Category 1 CreditsTM.Physicians should claim only the credit commensurate with the extent of their participation in theactivity.

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!January - July 2012

FELLOW MEMBERSHIP(Candidates pending Board of Directors approval 9/2012)

ADAM BECKER, MD, DURHAM, NC NAVEEN BHANDARKAR, MD, IRVINE, CA

CRAIG CALLOWAY VISALIA, CAGREGORY ESSELMAN, MD, AIKEN, SC JOHN LINDGREN, MD, PORTLAND, OR

ANKIT PATEL, MD, JOLIET, ILALLAN ROSENBAUM, MD, POWELL, TN

REGULAR MEMBERSHIPDAVID J BAILEY, MD, LUFKIN, TX

ANGELA BLOUNT, MD, BIRMINGHAM, ALMARINA BORUK, MD, FOREST HILLS, NY

EUGENE G BROWN, III, MD, MT. PLEASANT, SC KEVIN BROWNE, MD, SAN ANTONIO, TX

DAVID CARADONNA, MD, LYNNFIELD, MACHRIS CHACKO, MD, EVANSVILLE, IN LORI CUDONE, MD, CHARLESTON, IL

KENNETH DEEM, MD, WILLIAMSVILLE, NYJEFFREY FEINFIELD, MD, THOUSAND OAKS, CA

SAMUEL J GIRGIS, MD, HINSDALE, ILROBERT A GUIDA, MD, NEW YORK, NY

JONATHAN HAFNER, MD, SAN ANGELO, TX HEATHER HERRINGTON, MD, BURLINGTON, VT

HABIB JAMAL, MD, RYE BROOK, NYEVELYNE KALYOUSSEF, MD,

NORTH BRUNSWICK, NJ ESTHER KIM, MD, CHEVY CHASE, MD, MICHAEL KIM, MD, LOS ALAMITOS, CA

BRYAN LANSFORD, MD, JONESBORO, AR WILLIAM LEIGHT, MD, BENNINGTON, NE JAMIE LITVACK, MD, WASHINGTON, DC

JOHN MCINTYRE, MD, DALLAS, TX DAVID D MORRISSEY, MD, BOULDER, CO JAYAKAR V NAYAK, MD, PALO ALTO, CA

MONICA PATADIA, MD, MAYWOOD, ILFRANCISCO PERNAS, MD, CORAL GABLES, FL

BRIAN PESHEK, MD, OKEMOS, MI EVAN RANSOM, MD, SAN FRANCISCO, CA

CHESTER ROLLINS, MD, ATLANTA, GACHRISTOPHER SCHMIDT, MD, OCALA, FL

ROBERT SCIACCA, MD, HOOVER, ALSTEPHANIE SMITH, MD, CHICAGO, IL

RESIDENT MEMBERSHIPRICHARD ALEXANDER, MD, WINSTON SALEM, NC

MUHAMAD AMINE, MD, PALO HILLS, ILPETER ANDERSON, MD, CINCINNATI, OH MARTIN ANDERSON, MD, ST. LOUIS, MO

SCOTT ASHER, MD, BIRMINGHAM, ALSARFARAZ BANGLAWALA, MD, TORONTO

ONTARIO CANADABENNETT BARCH, MD, CHICAGO, ILHENRY BARHAM, MD, DENVER, CO

JEFFREY BEDROSIAN, MD, NEW YORK, NYMARK BEEN, MD, CHICAGO, IL

ASHLEY BIDDY, MD, WINSTON SALEM, NC BRIAN BOYCE, MD, COLUMBUS, OH

SCOTT BURGE, MD, OKLAHOMA CITY, OK JOHN CARTER, MD, NEW ORLEANS, LA

JUSTIN CASEY, MD, DENVER, CO ERIC CERRATI, MD, NEW YORK, NY

PHILIP CHAFFIN, MD, MINNEAPOLIS, MN KYLE CHAMBERS, MD, BOSTON, MAJOHN CHI, MD, PHILADELPHIA, PA

D-YEON CHO, MD, MENLO PARK, CAGARRET CHOBY, MD, PITTSBURGH, PA

JUSTIN COHEN, MD, NEW YORK, NYEMILY CROZIER, MD, DALLAS, TX

JOHN DAHL, MD, CHAPEL HILL, NC KARA DAVIS, MD, PITTSBURGH, PARAJ DEDHIA, MD, PITTSBURGH, PA

KARA DETWILLER, MD, PORTLAND, OR GREGORY DION, MD, SAN ANTONIO, TX

JUSTIN DOUGLAS, MD, MORGANTOWN, WV JUSTIN DOUGLAS, MD, MORGANTOWN, WV

DEEPAK DUGAR, MD, CHAPEL HILL, NC DANIEL FADEN, MD, SAN FRANCISCO, CA

JOHN FARIA, MD, TONAWANDA, NYBRENT FELDT, MD, SAN ANTONIO, TX

JAY FERRELL, MD, HOUSTON, TX INESSA FISHMAN, MD, SHAWNEE, KS

MARK FRIEDEL, MD, PHILADELPHIA, PAARTUR GEVORGYAN, MD, TORONTO

ONTARIO CANADADANIEL GIVENS, MD, SALT LAKE CITY, UT

JASON GOODWIN, MD, COLUMBIA, M0 EVAN GRABOYES, MD, ST. LOUIS, MO


JOSE GURROLA, MD, IOWA CITY, IAANNA HANG, MD, CHAPEL HILL, NC AVRAM HECHT, MD, SAN DIEGO, CA

IAN HUMPHREYS, MD, ROYAL OAK, MI CHRISTOPHER ITO, MD, TAMPA, FL

CHRISTIAN JACOB, MD, NEW ORLEANS, LAMATTHEW JOHNSON, MD, MADISON, WI

MATTHEW JUNG, MD, ST. LOUIS, MO SALLY KAMAL, MD, SACRAMENTO, CA

WEE TIN KAO, MD, ST. LOUIS, MO GRACE KIM, MD, CHAPEL HILL, NC

JAE KIM, MD, BUFFALO, NYANNA KNISELY, MD, PITTSBURGH, PA

JEFFREY KSIAZEK, MD, CINCINNATI, OH LEVI LEDGERWOOD, MD, SACRAMENTO, CA

JENNIFER LEE, MD, PHILADELPHIA, PAHEATHER LEE, MD, LOUISVILLE, KY

MICHAEL LERNER, MD, NEW HAVEN, CTELLIOT LIEBERMAN, MD, CHICAGO, IL

MOHAMMAD MA KAZEMIZADEL-GOL, MD,ROSEVILLE, MN

CHADI MAKARY, MD, MORGANTOWN, WV JONATHAN MASLAN, MD, WINSTON SALEM, NC

STANLEY MCCLURG, MD, COLUMBUS, OH JOSH C MEIER, MD, BOSTON, MASEAN MILLER, MD, ST. LOUIS, MO

SHAULNIE MOHAN, MD, ST. LOUIS, MO DAVID MONTAG, MD, MINNEAPOLIS, MN

JEFFREY MYHILL, MD, TAMPA, FLJAVAN NATION, MD, DETROIT, MI

JENNIFER NELSON, MD, SPRINGFIELD, ILJOHN NEWMAN, MD, TRUSSVILLE, AL

STEPHEN NOGAN, MD, COLUMBUS, OH RYAN OROSCO, MD, SAN DIEGO, CA

JAMES OWUSU, MD, MINNEAPOLIS, MN ANGELA PADDACK, MD, LITTLE ROCK, AR

NEEL PATEL, MD, CHICAGO, ILSAPNA PATEL, MD, SEATTLE, WANEHA PATEL, MD, NEW YORK, NY

ANJU PATEL, MD, BOSTON, MAANGEL PEREZ, MD, SUFFOLK, VA

BRANDON PRENDIS, MD, SAN FRANCISCO, CASETH PROSS, MD, SAN FRANCISCO, CA

MICHAEL PURKEY, MD, PHILADELPHIA, PAPHILIP ROBB JR, MD, LITTLE ROCK, AR

MICHAEL RODRIGUEZ, MD, STERLING HEIGHTS, MI

JOSEPH ROHRER, MD, SAN ANTONIO, TX BENJAMIN ROMAN, MD, PHILADELPHIA, PAJASON ROOS, MD, ROCHESTER HILLS, MI DANIEL SACKS, MD, WEST HARTFORD, CT

MARY SCADUTO, MD, ST. LOUIS, MO AHMAD SEDAGHAT, MD, BOSTON, MADHAVE SETABUTR, MD, HERSHEY, PAROSS SHOCKLEY, MD, NASHVILLE, TN NATALIE SILVER, MD, LEXINGTON, KYEUGENE SON, MD, LEAGUE CITY, TX

CHRISTIAN SONERU, MD, CHICAGO, ILNICHOLAS SORREL, MD, HOUSTON, TX

AMANDA STAPLETON, MD, PITTSBURGH, PATOBY STEELE, MD, SACRAMENTO, CA

PATRICK STEVENS, MD, HARTFORD, CTMATTHEW STEVENS, MD, SAN ANTONIO, TX

MARY STRAUB, MD, SAN ANTONIO, TX THOMAS TAMURA, MD, BURLINGTON, VT

LUIS TARRAT, MD, SAN JUAN, PR AARON THATCHER, MD, ANN ARBOR, MI

CHRISTOPHER THOMPSON, MD, LOS ANGELES, CABRIAN THORP, MD, CHAPEL HILL, NC

ZACHARY VANDEGRIED, MD, HUNTINGTONWOODS, MI

VICTORIA VARGA-HUETTNER, MD, CHICAGO, ILJENNIFER VILLWOCK, MD, LIVERPOOL, NY

DARSHNI VIRA, MD, LOS ANGELES, CAPETER VOSLER, MD, PITTSBURGH, PA

EVAN WALGAMA, MD, DALLAS, TX JEFFREY WATSON, MD, SAN DIEGO, CA

ADAM WEISSTUCH, MD, ALBANY, NYTHOMAS WILLSON, MD, SAN ANTONIO, TX

JOSHUA WOOD, MD, BARTLETT, TN MEGAN WOOD, MD, WINSTON SALEM, NC

HARRY WRIGHT, MD, NASHVILLE, TN

INTERNATIONAL MEMBERSHIPDANIEL DUTRA, MD, SAO PAULO BRAZIL

SAMY S ELWANY, MD, ALEXANDRIA EGYPTGABRIELLE HOLANDA, MD, PARAIBA BRAZIL

RAED A RTAIL, MD, LEBANON BEIRUTEULALIA SAKANO, MD, SAO PAULO BRAZIL

VISHNU SUNKARANENI, MD, SURREYUNITED KINGDOM


Constitution - Floor Plans


• 8th ANNUAL DAVID W. KENNEDY LECTURESHIPGuest Lecturer Donald C. Lanza, M.D.,

“Re-thinking Inverted Papilloma in 2012 - Challenges & Novel Treatment Strategies”

• DISSECTION DEMONSTRATIONProfessor Heinz Stammberger, Techniques in ESS

5858thth Annual Meeting of the ARSAnnual Meeting of the ARSSeptember 8, 2012 Washington, DCGuest Countries: France, Japan, and South Africa

Plus...

•Resident’s/Fellow’s in Training Luncheon •Exhibit Hall•Attendees Luncheon with Exhibitors•Meet the Authors” Wine & Cheese Poster Reception

(Supported by Intersect ENT)


Breakfast SymposiumSeptember 8, 2012

Recent Innovations in Rhinology: The Hottest Topics with Breakfast

Timothy Smith, MDModerator

Heinz Stammberger, MDAutologous Fibrin Glue

Jim Stankiewicz, MDBalloons in the Office

Roy Casiano, MDPowered Instruments

Andy Murr, MDSteroids and Stents

Special Thanks for Supporting:Entellus, Entrigue, Intersect, Laurimed, Medtronic

Oral Presentations

Plenary Session September 8, 2012Constitution A/B8:00 AMWelcomeTodd Kingdom, MD, Program Chair

8:05 AMPanel Discussion: Managing & AvoidingComplications in RhinologyModerator: James Stankiewicz, MDPanelists: David Kennedy, MD, Devyani Lal,MD, Richard Orlandi, MD, David Poetker, MD,Kevin Welch, MD

8:45 AMPresidential Address Michael Setzen, MD.9:00 AMBusiness Meeting

9:05 AMDiscussions in Rhinology: How The ExpertsHandle It? Moderator: Todd Kingdom, MDThe Experts: Ralph Metson, MD, HeinzStammberger, MD

9:30 AMBreak with Exhibitors - Constitution C

10:00 AMIntroduction of the 8th Annual KennedyLecturer Peter Hwang, MD

The 8th Annual Kennedy Lecture - Donald Lanza, MDRe-thinking Inverted Papilloma in 2012 -Challenges & Novel Treatment Strategies

10:45 AMIntroduction of Professor HeinzStammbergerMichael Setzen, MD

Demonstration Dissection of FESS - Heinz Stammberger, MD

12:00 PMLunch with Exhibitors - Constitution C

Clinical Rhinology SessionSeptember 8, 2012Constitution A

1:00 PMIntroductionTodd Kingdom, MDARS President-Elect & Program Chair

____________________________________

Moderators: Parul Goyal, MD, Kevin Welch, MD

1:05 PMEvaluation of Post-operative NasalIrrigations with Budesonide for Patients withPolyposis: A Blinded RandomizedControlled TrialRounak B Rawal, BA, Allison M Deal, MS,Charles S Ebert, Jr, MD, MPH, Mitchell R Gore,MD, PhD, Brent A Senior, MD, FACS, Adam MZanation, MDChapel Hill, NC USA

Background: Patients with chronic rhinosinusitis with polypo-sis (CRSwNP) often undergo surgery.Budesonide is often added to normal saline(NS) irrigations, although no evidence exists forits use for all-cause CRSwNP.

Objective: This prospective, randomized, controlled trialcompares two accepted modes of post-surgicaltreatment in patients with CRSwNP.

Methods: Subjects were prospectively enrolled to NS orNS + budesonide arms. Patients were evaluatedat the pre-operative visit and three post-opera-tive visits (POV): POV1 (1-2 weeks post-op),POV2 (3-8 weeks post-op), and POV3 (3 - 6months post-op). Patients completed threequality of life (QOL) questionnaires (SNOT - 22,RSOM-31, and RSDI), two endoscopic gradingscores (POSE and Lund - Kennedy Scores) andtwo measures of olfaction (UPSIT and the PEAtest).

Results: Forty-eight patients were enrolled, with 23patients in the NS arm and 25 patients in the NS



+ budesonide arm. Patients experienced signifi-cant improvement in all three QOL surveys byPOV2 and POV3, although the degree ofimprovement between arms was not significant(p = 0.40, p = 0.79, and p = 0.78). Patients hadsignificant improvement in both endoscopyscores, although the degree of improvementbetween arms was not significant (p = 0.81, p =0.73). Patients in neither arms had significantimprovement in either olfaction tests.

Discussion: Although both NS and NS + budesonide treat-ments improve QOL and endoscopic scores forpost-polypectomy patients, neither group signifi-cantly increases QOL and endoscopic scoresas compared to the other. Olfaction was not sig-nificantly improved in either group.

1:11 PMNational Survey on the use of PreoperativeSystemic Steroids in Endoscopic SinusSurgeryJavier Gonzalez-Castro, MD, Jose Busquets, MDSan Juan, PR United States

Introduction: The use of preoperative systemic steroids (SS)in Endoscopic Sinus Surgery (ESS) has been atopic of debate amongst Otolaryngologists formany years now. Until recently, most of the evi-dence to support SS use in ESS was largelyanecdotal and based on expert opinion. Evenwith some recent randomized and blinded trialsthat have emerged, opinions amongst expertsin the field are highly variable. The objective ofthis study is to identify and report the practicepatterns of experts in the field regarding the useof pre-operative SS.

Methods: A survey instrument was developed usingSurveyMonkey® and sent to active members ofthe American Rhinologic Society (ARS).Responses to questions regarding SS use, regi-men and benefits were recorded anonymously.

Results: A total of 173 members answered the question-naire. Although most respondents believe thatthere is inadequate evidence to justify their use,88.82% of the study population do in fact usepre-operative SS in their practice. The mostcommon reason for using SS amongst respon-

dents is Chronic Rhinosinusitis with Polyps(CRSwP), which is consistent with the literatureavailable. We also found statistically significantdifferences between SS use in private versusacademic practice, showing a trend towardsmore aggressive management in the academicaffiliated physicians.

Conclusions: The current study shows that most of therespondents in our group do in fact see anadvantage in the use of SS before ESS. Thedata also highlights the opinion of most expertsthat more research with higher levels of evi-dence is still lacking.

1:17 PMOral Corticosteroids in the Management ofAdult Chronic Rhinosinusitis with and with-out Nasal Polyps:David M Poetker, MD, MA, Luke A Jakubowski,MD, Devyani Lal, MD, Peter H Hwang, MD,Erin D Wright, MDCM, Med, Timothy L Smith,MD, MPHMilwaukee, WI USA

Introduction:Oral steroids are commonly used in the man-agement of chronic rhinosinusitis with and with-out nasal polyps (CRSwNP, CRSsNP, respec-tively). Past reports have included evaluation ofthe evidence for the use of oral steroids in CRSsubtypes. However, a review with evidence-based recommendations for all CRS subtypeshas never been performed. The purpose of thisarticle is to provide a comprehensive, evidence-based approach for the utilization of oralsteroids in the management of CRS.

Methods: A systematic review of the literature was per-formed following recommendations of theClinical Practice Guideline Manual, Conferenceon Guideline Standardization, and Appraisal ofGuidelines and Research.

Evaluation: Inclusion criteria were: adult population = 18years old; chronic rhinosinusitis, oral steroids asthe treatment group; and clearly defined pri-mary clinical end-point.


Results: This review identified and evaluated the litera-ture on the use of oral steroids for CRSwNP,CRSsNP, allergic fungal sinusitis (AFS), and theuse of oral steroids in the peri-operative periodin these patients. Recommendations based onevidence, benefit/harm assessment, and valuejudgments are made.

Conclusion: Oral steroids are strongly recommended forshort-term management of CRSwNP. Oralsteroids are also recommended for manage-ment of AFS. Oral steroid use in CRSsNP isoptional due to insufficient strong evidence.Oral steroids are also strongly recommended inthe peri-operative period for CRSwNP and AFS.There is no recommendation for oral steroidsuse in the peri-operative period in patients withCRSsNP. The risks of oral steroids are rare, butsignificant adverse effects must be considered.

1:23 PMComparison of Nasal Sprays and Irrigationsin the Delivery of Topical Agents to theOlfactory MucosaKent Lam, MD, Bruce K. Tan, MD, Jennifer M.Lavin, MD, Eric Meen, MD, David Conley, MDChicago, IL United States

Background: Treatment of sinonasal diseases utilizes topicalagents administered using various applicationtechniques, but few prior studies examine theirdistribution in the olfactory mucosa.

Objective: To compare the distribution efficiency of nasalirrigations compared to nasal sprays within thehuman olfactory cleft.

Methods: Eight cadaveric heads, providing a total of 15nasal sides, underwent treatment with dilutedmethylene blue solution. Application utilizedpressurized sprays followed by squeeze-bottleirrigations applied according to manufacturerinstructions. Prior to treatment and followingeach method of agent delivery, videos andimages from six standardized anatomical posi-tions were recorded by nasal endoscopy. Threereviewers blinded to the method of agent deliv-ery scored the images, using an ordinal scale todescribe extent and relative intensity of staining.

Results: Irrigations demonstrated a greater degree ofpenetration than sprays within the sphenoeth-moid recess (p<0.05), superior turbinate(p<0.05), and superior olfactory cleft (p<0.05).While sprays coated 41-60 percent of a com-posite of these olfactory subsites, irrigationscovered 81-100 percent of the same region.Sprays and irrigations, however, were compara-ble in the extent of staining at the vestibule(p=0.05), inferior turbinate (p<0.05), and middleturbinate (p<0.05).

Conclusions: Compared to sprays, irrigations provide a moreeffective method to deliver topical agents to theanterior, posterior, and superior aspects of theolfactory cleft. The thorough distribution ofsqueeze-bottle irrigations to the olfactorymucosa has important implications for improv-ing the delivery of therapeutic agents in periph-eral olfactory disorders, but also requires recog-nition and testing of irrigation-based productsfor potential olfactory toxicities.

1:29 PMDiscussion/Q&A

____________________________________

Moderators: Christopher Church, MD,Mickey Stewart, MD

1:37 PMMedical Therapy Versus Surgery for ChronicRhinosinusitis: A Prospective, Multi-institu-tional Study with One-Year Follow-upTimothy L. Smith, MD, MPH, Robert C. Kern,MD, James N. Palmer, MD, Rodney J.Schlosser, MD, Rakesh K. Chandra, MD,Alexander G. Chiu, MDPortland, Oregon USA

Introduction:This study evaluates one year outcomes inpatients with chronic rhinosinusitis (CRS) whowere considered surgical candidates by studycriteria and elected either medical managementor endoscopic sinus surgery (ESS). In addition,some patients initially enrolled in the medicaltreatment arm crossed-over to the surgery armduring the study period and their respective out-comes are evaluated.


Methods: Adult subjects with CRS who failed initial med-ical therapy were prospectively enrolled into anon-randomized, multi-institutional cohort.Subjects were included in one of three cohorts:medically managed, surgically managed, orcross-over (from medical to surgical).The pri-mary outcome measure was disease-specific,quality-of-life(QOL). Bivariate and multivariateanalyses compared QOL improvement betweencohort groups.

Results: Baseline comorbidity, QOL, and other diseaseseverity measures were not different betweenthe three cohorts. With one year follow up, sur-gical patients (n=65) reported significantly moreimprovement than medically managed patients(n=33; RSDI,p=0.039; CSS,p=0.018).Seventeen subjects who had initially electedmedical management crossed-over to surgeryduring the follow-up period. QOL in thecrossover cohort was initially stagnant or wors-ening followed by improvement after ESS(RSDI,p=0.035; CSS,p=0.070). At one-year fol-low-up, higher frequency of improvement wasfound in the surgical cohort vs. medical cohortfor several outcomes (total CSS: 70.8% vs.45.5%; OR:3.37[95% CI:1.27,8.90]; p=0.014).

Conclusions: With one year of follow-up, patients electingESS experienced significantly higher levels ofimprovement in outcomes as compared topatients managed by medication alone. Inaddition, a crossover cohort who initially electedmedical management experienced improve-ment in several outcomes after crossing over toESS.

1:43 PMDiagnostic Paradigms in the Management ofChronic Rhinosinusitis from the PrimaryCare Provider Perspective: A Cost-Based DecisionAnalysisRandy M Leung, MD, Rakesh K Chandra, MD,David B Conley, MD, Robert C Kern, MD, BruceK Tan, MDBarrie, Ontario Canada

Background: To diagnose chronic rhinosinusitis (CRS),guidelines require either endoscopic or comput-

ed tomography (CT) findings of inflammation.To a primary care physician (PCP), this meansa referral to an otolaryngologist or obtaining aCT scan for confirmation. Unfortunately, despitecharacteristic symptoms, it has been estimatedthat in primary practice, as low as 4% ofpatients actually have CRS - versus 20-36% intertiary Rhinology clinics. The differential forCRS symptoms includes diagnoses such asmigraine disorders and rhinitis, which are oftenmanaged medically by primary care doctors.When these patients are managed by otolaryn-gologists, recent data has suggested CT ismore cost-efficient when applied earlier in thediagnostic algorithm.

Objective: This study aims to identify a cost-efficient prac-tice algorithm for primary care.

Methods: A cost-based Markov-chain decision analysisbased on literature reported probabilities, andMedicare costs was constructed for two scenar-ios: PCPs who are comfortable trying first linetreatment for CRS, rhinitis and migraine, andPCPs who refer patients with these conditionsto specialists for diagnosis and management.Modeling encompassed the time of initialencounter through initiation of definitive first linetherapy.

Results: Confirming diagnosis with CT scanning prior totreatment is less costly than treatment/referralbased on an unconfirmed presumed diagnosis ofCRS. This applies to scenarios where PCPs arecomfortable initiating first-line treatment as wellas PCPs who prefer to refer.

Conclusion: In all scenarios, confirming diagnosis with CTscanning prior to treatment or referral is morecost-efficient than presuming a diagnosis ofCRS based on symptoms alone.


1:49 PMEffectiveness of Azithromycin as an Add-onTherapy to Steroid Irrigations in High-RiskPost-Endoscopic Sinus Surgery PatientsAnastasios Maniakas, BSc, Martin-YvonDesrosiers, MD, FRCSCMontreal, Quebec Canada

Objectives: Chronic rhinosinusitis (CRS) has a high poten-tial for recurrence following endoscopic sinussurgery (ESS), despite post-ESS corticosteroidirrigation. Azithromycin (AZI) is a macrolideantibiotic with anti-inflammatory properties thatmay be of benefit in such steroid-unresponsivepatients. Our objectives were to evaluate theeffectiveness of the addition of AZI in high-riskpatients failing standard management and toidentify predictive factors for treatment failure.

Methods: A retrospective study of the post-operative evo-lution of all patients undergoing ESS for CRS in2010 by a single surgeon was undertaken.Patients deemed at high risk of recurrencereceived BID nasal irrigation with 0.5mg ofbudesonide (BUD) in 240ml of saline, post-ESS. Patients showing signs of endoscopicrecurrence at four months, despite BUD, weregiven azithromycin 250mg 3x/week (AZI) aspart of their treatment regimen.

Results: 57 high-risk patients were operated on betweenJanuary and December 2010. At 4 months,63.2% (36/57) had a favorable outcome withBUD. Twelve (12/21) non-responders to BUDreceived AZI, with an additional 66.7% (8/12)having a favorable response. Failure of BUDwas associated with female gender (p=0.048),having elevated alpha-1-antitrypsin levels(p=0.037), and lower recovery rates ofStaphylococcus aureus (BUD non-responders:28.6%; responders: 48.2%; p=0.160). The AZInon-responder group was too small for compar-ison.

Conclusion: A significant sub-group of high-risk patientsshowing disease recurrence after ESS, despitecorticosteroid irrigations, may respond to theaddition of AZI as part of their therapy. Thesefindings suggest that alternate anti-inflammatoryagents may be required for an optimized man-agement of steroid-unresponsive CRS.

1:55 PMA Prospective Study of Post-operativeSymptoms in Sinonasal Quality-of-LifeFollowing Endoscopic Endonasal PituitarySurgeryJeffrey C Bedrosian, MD, Roheen Raithatha,MD, Edward D McCoul, MD, MPH, Vijay KAnand, MD, Theodore H Schwartz, MDNew York, NY USA

Objectives: To assess prospectively, post-operative changesin sinonasal quality-of-life symptoms followingendoscopic endonasal pituitary surgery.

Methods: Fifty-two patients were prospectively assessedwith the Anterior Skull Base Questionnaire(ASBQ) preoperatively and up to 1 year postop-eratively at each subsequent office visit. A sub-set of these data was analyzed to assess theeffect of endoscopic pituitary surgery on post-operative taste, smell, appetite, nasal secre-tions and vision.

Results: Using the ASBQ, a validated quality-of-lifeinstrument, we prospectively assessed patient-reported symptoms following endoscopicendonasal pituitary surgery. Compared to pre-operative scores, both taste (3.69 vs. 2.89,p=<0.001) and smell (3.76 vs. 2.58, p=<0.001)were significantly decreased by 6 weeks post-operatively. However, by 6 months post-opera-tively both taste and smell scores were not sig-nificantly different from pre-operative results(3.41, p=0.23 and 3.18, p=0.05, respectively).No significant change in appetite or nasalsecretions was observed in the post-operativeperiod. Patients reported significant subjectiveimprovement in vision by 3 weeks post-opera-tively with durable results at 1 year (2.80 vs.3.33, p=0.04 vs. 3.59, p=0.03, respectively).

Conclusions: Endoscopic endonasal pituitary surgery tran-siently decreases patient-reported perceptionsof taste and smell in the early post-operativeperiod. These results steadily improve by 6weeks post-operatively, with no significant dif-ference in quality-of-life scores by 6 monthspost-operatively. No change in appetite ornasal secretions was observed. Patients report-ed steady subjective improvement in visionbeginning at 3 weeks post-operatively.



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Moderators: Subinoy Das, MD, Charles Ebert, MD

2:09 PMValidation of the Kennedy Osteitis Score toClinico-histologic Features of ChronicRhinosinusitisPresented by: Richard Harvey, MDKornkiat Snidvongs, MD, Rohan McLachlan,Raymond Sacks, MD, Peter Earls, MD, Richard Harvey, MDSydney, NSW Australia

Background: Osteitis is a feature of chronic rhinosinusitis(CRS) and often associated with recalcitrantdisease. Radiological characteristics of osteiticsinus changes are commonly reported in prac-tice but the clinical and pathologic significanceis poorly defined. The objective of this studywas to validate the Kennedy Osteitis Score(KOS) to clinico-histologic features of CRS.

Methods: A cross-sectional study of CRS patients under-going sinus surgery was conducted. Osteitiswas scored radiologically using KOS.Associations between osteitis and histopatholo-gy, symptoms, SNOT-22, endoscopy, CTmucosal score and seromarkers wereassessed. Interobserver correlation coefficientwas performed. Additionally, the KOS was cor-related to an alternate Global Osteitis Score forvalidation.

Results: 88 patients were assessed (45.5% female, age50.3±13.6 years). 45 (51.1%) patients hadosteitis. Patients with KOS greater than 0, hadgreater endoscopy score (6.1±2.9 versus4.4±3.6, p=0.03) and CT score (14.0±6.0 ver-sus 10.1±5.7, p<0.01) than those withoutosteitis. There was no difference in symptomscore (2.4±1.3 versus 2.4±1.1, p=0.89) andSNOT-22 (2.0±1.0 versus 1.9±1.1, p=0.56) inpatients with and without osteitis. KOS washigher in patients with tissue eosinophilia >10/HPF (3.0(1.0-5.3) v 0.0(0.0-4.0), p=0.03)and serum eosinophilia >0.3 x109/L (4.0(2.0-

7.0) versus 1.0(0.0-4.0), p<0.01). Importantly,this was also true for those without prior sur-gery.The interobserver correlation coefficientwas good (R=0.86, p<0.001). There is a signifi-cant correlation between KOS and GlobalOsteitis Score (R=0.93, p<0.001).

Conclusions: KOS is a simple, easy and reproducible scale inassessing osteitic bones in patients with CRSand can predict measures of severity ineosinophilic rhinosinusitis.

2:15 PMRecalcitrant Rhinosinusitis, Innate Immunity,and Mannose-Binding LectinJeb M Justice, MD, Donald C Lanza, MDSt Petersburg, FL USA

Background/Purpose:Mannose-Binding Lectin (MBL) is part of innateimmunity and is involved in opsonizing bacteriaby tagging the surface of intruding microbes.MBL deficiency is present in up to 7% of thepopulation and has been implicated in recurrentrespiratory tract infections in children. MBL defi-ciency has not been explored in rhinosinusitis,but is associated with increased mortality inadult pneumoccocal infection. The purpose ofthis report is to describe a tertiary rhinologypatient experience with MBL deficiency andrecalcitrant rhinosinusitis.

Methods: This retrospective case series report character-izes patients with low MBL levels from January2010 to June 2012. Indications for MBL testing,sinus culture data, immunological testingresults, and treatments used to control rhinosi-nusitis are described.

Results: MBL levels were deficient in 10/34 (29.4%) ofpatients tested. IgG subclasses were abnor-mally low in 4/10, while IgA was normal in alland IgM was normal in 9/10 patients.Staphylococcus aureus, coagulase-negativestaphylococcus species, and pseudomonasaeruginosa, known to be "tagged" by MBL,were the most common organisms grown onculture. Treatments included culture directedsystemic antimicrobial therapy and topicalsteroids/antibiotics.


Conclusions: MBL, an important component of the lectincomplement pathway and innate immunity, ispossibly associated with recalcitrant adult rhi-nosinusitis. Steroid/antibiotic irrigations appearto benefit patients with recalcitrant rhinosinusitisand possibly those with MBL deficiency. Giventhat the prevalence of MBL deficiency in thiscase series is 4 times that seen in the normalpopulation, additional investigations are war-ranted to further elucidate the role of MBL defi-ciency in rhinosinusitis.

2:21 PM The Effect of Positive Intraoperative Cultureon Quality of Life Improvement AfterEndoscopic Sinus Surgery for ChronicRhinosinusitisZi Zhang, MD, Alexander G. Chiu, MD, Noam A.Cohen, MD, PhD, Nithin D. Adappa, MD,James N. Palmer, MDPhiladelphia, PA USA

Introduction: The effect of positive culture on endoscopicsinus surgery (ESS) outcome is unclear. Weaim to determine whether positive intraopera-tive culture is associated with quality of life(QOL) improvement after ESS for chronic rhi-nosinsitis (CRS), especially Staphylococcusaureus and Pseudomonas aeruginosa.

Methods: Consecutive adult CRS patients who underwentESS were prospectively enrolled from 2007 to2011. The 22 item Sinonasal Outcome Test(SNOT-22) was used to measure QOL beforeESS, 1-, 3- and 6-month after ESS. Positiveintraoperative bacterial culture was defined asany isolates of Staphylococcus aureus,Streptococcus pneumonia, Haemophilusinfluenza, Moraxella catarrhalis, Pseudomonasaeruginosa, other gram-negative rods, oranaerobes. Patients' demographics, comorbidi-ties, and medication use were collected beforeESS and controlled in the linear mixed-effectsregression model to assess the associations.

Results: 379 CRS patients completed baseline SNOT-22and had successful bacterial culture, and 35.4%of them were culture positive. The mean SNOT-22 scores before ESS, 1-, 3- and 6-month afterESS were 39±23, 19±19, 20±19 and 19±18

respectively, which showed clinically significantimprovement after ESS. CRS patients with pos-itive intraoperative cultures had significantlyworse QOL at 6-month follow-up compared toculture negative patients (23±21 vs. 17±14,p=0.031), and CRS patients with S. aureus hadsignificantly worse QOL at 3-month follow-upcompared to the other patients (27±27 vs.18±16, p= 0.019).

Conclusions: CRS patients with positive intraoperative cul-tures have less improvement of QOL during fol-low-ups, but this difference is not significantimmediately after ESS. Presence of positiveculture at surgery places patients in a negativeprognostic category.

2:27 PMComparison of Endoscopically-Guided Swabversus Aspirate Culture Techniques in Post-FESS Patients: Blinded, ProspectiveAnalysisEvan Walgama, MDDallas, TX USA

Introduction: Culture-directed antibiotic therapy remainsimperative in the management paradigm ofchronic rhinosinusitis (CRS). The objective ofthis study was to conduct a prospective, blindedcomparison of endoscopically-guided swab vs.aspirate cultures from the same sinonasal sitein patients presenting with acute infectiousexacerbation post-sinus surgery.

Methods: Fifty patients were prospectively enrolled in atertiary care rhinology clinic. At the conclusionof the study, all cultures were unblinded todetermine mean culture yield, most commonpathogens, potential contaminants (defined aspresence of scant or rare growth of commensalorganisms), and therapeutic correlation.

Results: The mean patient age was 49.2 years and 60%were females. Thirty-eight and 12 patients hadundergone previous endoscopic sinus and skullbase surgery, respectively. All patients had evi-dence of symptomatic exacerbation with puru-lence on endoscopy. There were mean of 1.24pathogens assayed per aspirate culture versusmean of 1.06 per swab culture (p-value = 0.22).


The prevalence of Pseudomonas aeruginosawas 42% for suction cultures versus 30% forswab cultures. The prevalence ofStaphylococcus aureus was 44% for suctioncultures versus 42% for swab cultures. Therewere 8 and 11 likely contaminants using aspi-rate and swab cultures, respectively.Therapeutic correlation was strong in 76%,moderate in 16%, and weak in 8% of patients.

Conclusions: The present blinded, prospective reviewdemonstrated higher culture yield with fewercontaminants with aspirate vs. swab culture,though difference was not statistically signifi-cant. Both aspirate and swab techniques areacceptable alternatives for endoscopic-derivedcultures in patients with post-FESS infectiousexacerbations.


2:41 PMBreak with Exhibitors - Constitution C

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Moderators: David Conley, MD, Jeffrey Suh, MD

3:10 PMQuantification of Airflow into the MaxillarySinuses Before and After FunctionalEndoscopic Sinus SurgeryDennis O. Frank, PhD, Adam M. Zanation, MD,Vishal H. Dhandha, BS, Charles S. Ebert, Jr,MD, Brent A. Senior, MD, Julia S. Kimbell, PhDChapel Hill, NC USA

Objective: Increases in maxillary sinus airflow followingfunctional endoscopic sinus surgery (FESS) areunknown, yet this information is needed to eval-uate potential mucosal drying. The goal of thisstudy is to quantify the effects of FESS on air-flow into the maxillary sinuses in four chronicrhinosinusitis (CRS) patients using computa-tional fluid dynamics (CFD).

Methods: As part of a clinical trial, pre- and post-operative

computed tomography (CT) scans of fourpatients who underwent bilateral or unilateralFESS were used to create three-dimensional(3D) reconstructions of the nasal airway andparanasal sinuses using Mimics™ (Materialise,Inc., Plymouth, MI). The size of the maxillaryantrostomies post-FESS ranged from 115-168mm2. Computational meshes were generatedfrom the 3D reconstructions using ICEM-CFD™(ANSYS, Inc., Canonsburg, PA) and steady-state, laminar inspiratory airflow was simulatedin each mesh using the CFD software FluentTM(ANSYS, Inc.) under physiologic pressure-driv-en conditions. Airflow into the maxillary sinuseswas estimated from the simulations and com-pared pre- and post-operatively.

Results: CFD simulations predicted that airflow into post-FESS maxillary sinuses was 5 to more than17,000 times higher than before surgery. Inaddition, on average, the speed of the flowgoing into the sinuses more than quadrupledafter FESS.

Conclusions: CFD simulations showed that the healed maxil-lary antrostomy after FESS can greatlyenhance airflow into the maxillary sinus by sev-eral fold. Correlations of increased post opera-tive airflow with water flux (drying) need to beexplored. These results have translational impli-cations for mucosal drying, nasal airflow turbu-lence and possibly post operative drug delivery.

3:16 PMComparison of Anatomical Abnormalities inPatients with Limited and Diffuse ChronicRhinosinusitisRavi Jain, MBChB, Nicholas Stow, MBBS,MD, Richard Douglas, MBChB, MDAuckland, Auckland New Zealand

Objectives: The role of anatomical abnormalities in thepathogenesis of chronic rhinosinusitis (CRS)remains unclear. We hypothesized that anatom-ical abnormalities causing obstruction of mucusdrainage would be more prevalent in patientswith limited CRS than in patients with pansi-nusitis who are more likely to have a general-ized mucosal abnormality.


Methods: The CT scans of patients with limited sinusitis(maxillary sinus and/or the ostio-meatal unit),patients with diffuse bilateral disease andasymptomatic controls were studied. Lund-Mackay (LM) scores were calculated, and thefrequency of anatomical abnormalities thatcould affect mucus drainage of the ostio-meatalregion was determined.

Results: The limited disease group comprised 22patients with 96 total anatomical variants (4.4+/- 2.0 (mean per patient +/- SD)). Average LMscores were 5.2 +/- 3.2. The diffuse diseasegroup comprised 28 patients with 70 anatomicalvariants (2.6 +/- 2.0 per patient). LM scoreswere 15.1 +/- 4.2. The control group had 27patients with 68 variants (2.5 +/- 1.4 perpatient). LM scores were 1.3 +/- 1.3. The fre-quency of anatomical variants in the limitedgroup was significantly higher than in the pansi-nusitis and control groups (p < 0.003). Therewas no significant difference in the number ofanatomical variations between the diffuse dis-ease and control groups.

Conclusion: These results suggest that patients with limitedCRS may be predisposed by anatomical vari-ants impairing drainage of the ostiomeatalregion and, pansinusitis (likely resulting fromgeneralized mucosal abnormality), is associatedwith a lower frequency of anatomical variantssimilar to the general population.

3:22 PMSubcutaneous Immunotherapy for AllergicRhinitis-an Evidenced Based Review withRecommendationsPresented by Elina Toskala, MDMichael T. Purkey, MD, Timothy L. Smith, MD,Berrylin J. Ferguson, MD, Elina Toskala, MD, PhD

Background: Allergic rhinitis is a common allergic diseasewith increasing prevalence in WesternSocieties. Medical therapy is first line treatment,and is aimed at reducing symptoms of IgE-mediated inflammation of the nasal passages.In patients with disease refractory to medicaltherapy, subcutaneous immunotherapy is anoption. The aim of this study is to review theefficacy and safety of subcutaneous

immunotherapy for seasonal and perennialallergic rhinitis.

Methods: A systematic review of the literature was per-formed from 2006-2011 and compared withdata from a 2007 Cochrane review onimmunotherapy for seasonal allergic rhinitis.We included all studies of level 1 evidence. Allforms of single extract immunotherapy wereconsidered. Studies with primary asthma relat-ed end-points were excluded. Primary end-points were instruments of clinical efficacy (i.e.symptom-medication scores) and adverseevents.

Results: We retrieved 12 level 1 studies for review. Intotal, 1,512 patients were randomized into treat-ment groups, alternative study groups (alterna-tive duration of therapy or SLIT), or placebo.Efficacy was evaluated based on reportedsymptom and/or medication score, validatedquality of life instruments, immunologicalassays, challenge testing, and adverse events.

Conclusion: Subcutaneous immunotherapy improves symp-tom and/or medication scores and validatedquality of life measures. In addition, associatedchanges in surrogate markers of immunologicprotection are observed. Subcutaneousimmunotherapy is safe when administered tocarefully selected patients and in settings capa-ble of responding to systemic reactions.Subcutaneous immunotherapy is recommendedfor patients with seasonal or perennial allergicrhinitis not responsive to conservative medicaltherapy, and whose symptoms significantlyaffect quality of life.

3:28 PMSinonasal Anatomic Variants and Asthmaare Associated with Faster Development ofChronic Rhinosinusitis in Patients withAllergic RhinitisAhmad R Sedaghat, MD, PhD, Stacey T Gray,MD, FACS, Claus O Wilke, PhD, David SCaradonna, MD, FACSBoston, MA USA

Background: Allergic rhinitis (AR) and chronic rhinosinusitis(CRS) are a major burden to the healthcare


system. Although no causal relationship hasbeen established, previous work has demon-strated the strong association of AR with CRS.

In this study, we sought to identify risk factorsthat may influence speed of development ofCRS in patients with AR.

Methods: Retrospective review of all patients diagnosedwith AR without CRS presenting to an otolaryn-gology clinic at a tertiary medical center as partof a multidisciplinary allergy evaluation betweenMarch 2004 and November 2011. Medicalrecords were evaluated for clinicodemographicfactors including age, gender, smoking history,medical comorbidities, categories of AR basedon formal allergy testing, the presence ofsinonasal anatomic variants on computedtomography as well as subsequent develop-ment of CRS.

Results: Faster progression to CRS in patients with ARwas associated with comorbid asthma (hazardratio [HR]=3.97) as well as sinonasal anatomicvariants, infraorbital cells (HR=7.39) and frontalintersinus cells (HR=68.03), on multivariate sur-vival analysis. A statistically significant but nega-tive interaction between infraorbital cells andfrontal intersinus cells suggests that concomitantpresence of both leads to a less than additiveincrease in the rate of CRS progression.

Conclusions: Sinonasal anatomical variants, infraorbital cellsand frontal intersinus cells, as well as comorbidasthma are associated with faster developmentof CRS in patients with AR. The presence ofthese clinical characteristics identifies patientswho should be counseled on compliance withmedical therapy and, perhaps managed moreaggressively for AR.


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Moderators: Jean Anderson Eloy, MD,Joseph Han, MD

3:42 PMCost-Effectiveness of EndoscopicSphenopalatine Artery Ligation versusPosterior Packing as First-line Treatment forPosterior EpistaxisRaj C Dedhia, MD, Shamit S Desai, BA, MA,Kenneth J Smith, MD, MS, Stella Lee, MD, CarlH Snyderman, MD, MBA, Eric W Wang, MDPittsburgh, PA USA

Introduction: The advent of endoscopic sphenopalatineartery ligation (ESPAL) in the control of posteri-or epistaxis provides an effective, low morbiditytreatment option. In the current practice algo-rithm, ESPAL is pursued after failure of posteri-or packing. Given the morbidity and limitedeffectiveness of posterior packing, we sought todetermine the cost-effectiveness of first-lineESPAL compared to the current practice model.

Methods: A standard decision analysis model was con-structed comparing "First-line ESPAL" and"Current Practice" algorithms. A literaturesearch was performed to determine event prob-abilities and published Medicare data providedcost parameters. The primary outcomes werecost of treatment and resolution of epistaxis.One-way sensitivity analysis was performed forkey parameters.

Results: Costs for the "First-line ESPAL" arm and"Current Practice" arm were $5,902 and$8,046, respectively. This difference of $2,144in favor of the "First-line ESPAL" arm wasincreased to $6,610 when the duration of nasalpacking was increased from 3 to 5 days.

Conclusion: This study demonstrates the cost-effectivenessof ESPAL as first-line therapy for posterior epis-taxis. Given the improved effectiveness andpatient comfort of ESPAL compared to posteriorpacking, ESPAL should be offered as an initialtreatment option for medically stable patientswith posterior epistaxis.


3:48 PMSonopet Ultrasonic Bone Aspirator VersusTraditional Instrumentation DuringEndoscopic Transsphenoidal Approach forPituitary Tumor ResectionHarry Michael Baddour Jr., MD, Michael D Lupa, MD, Zara M Patel, MDAtlanta, GA USA

Background: The Sonopet ultrasonic bone aspirator hasbeen used within neurosurgery, otolaryngologyand in other fields, but to our knowledge hasnot been reported in the literature for use inendoscopic transsphenoidal approaches (TSA)to the skull base. The study objective was tocompare use of the Sonopet versus traditionalcold steel instrumentation during TSA in termsof operative time and blood loss.

Methods: The study design was a prospective, random-ized, single-blinded controlled clinical trial. Thepopulation included patients who presented to atertiary care skull base center with pituitarytumors amenable to endoscopic resection.Participants were randomized to either anendoscopic approach using the Sonopet ultra-sonic bone aspirator or traditional steel instru-mentation. Outcomes measured were operativetime and blood loss for the approach and expo-sure portion of the procedure.

Results: A total of 130 patients underwent an endoscop-ic TSA using either the Sonopet aspirator(n=66) or traditional steel instrumentation(n=64). The use of the Sonopet resulted in asignificant reduction in both operative time(31.92 ± 3.04 minutes vs. 41.32 ± 2.75 minutes,p<0.0001) and blood loss (16.5 ± 5.37 millilitersvs. 22.57 ± 3.09 milliliters, p<0.0001) comparedto traditional steel instrumentation.

Conclusions: This study is, to our knowledge, the firstprospective, randomized, controlled clinical trialcomparatively demonstrating the speed andefficacy of the Sonopet bone aspirator for endo-scopic TSA to the skull base. The significantreduction in operative time and blood loss com-pared to traditional instrumentation providesevidence in favor of use of the Sonopet forthese procedures.

3:54 PMOrigins of Inverted Papilloma - Not relatedto HPV?Jeb M Justice, MD, Donald C Lanza, MDSt Petersburg, FL USA

Background/Purpose: Controversy exists in the literature regardingthe pathogenesis of inverted papilloma (IP) as itrelates to human papillomavirus (HPV).Histopathological studies of IP suggest anassociation is unlikely when dysplasia isabsent. The purpose of this report is todescribe the prevalence of HPV in non-dysplas-tic, early IP, and to summarize prior peer-reviewed publications evaluating the prevalenceof HPV in IP and in the general population.

Methods: This retrospective case series characterizesconsecutive patients with IP from January 2005to May 2012. Presence or absence of low/highrisk HPV was determined by standardized in-situ hybridization (ISH) DNA probes. Dysplasiawas identified from surgical histopathologyreports. Medline literature review to determinethe prevalence of HPV in IP without either mod-erate or severe dysplasia was performed.

Results: Average age was 64 years (range 40-84); gen-der:17 men-12 women. High and/or low riskHPV was present in 1/29 (3%) patients and1/29 (3%) had mild dysplasia. Literaturereview: HPV does not invade normal respiratoryepithelium, oral cavity HPV is present in 11.4%of a similar US population, while 85-95% ofcommon warts, condylomata acuminata andrespiratory papillomatosis are assocaited withHPV.

Conclusions: Given histological features and the low rate ofHPV in IP without dysplasia (3%), HPV doesnot appear to be related to the initial pathogen-esis of IP. It is postulated that this inflammatorypolyp is susceptible to HPV infection due to itsmetaplastic tissue surface and thus may berelated to the transformation of existing IP tosquamous cell carcinoma.


4:00 PMRisk Factors and Outcomes for Primary,Revision and Modified Lothrop (Draf 3)Frontal Sinus SurgeryYuresh S Naidoo, MD, Ahmed Bassiouni, MD,Mark Keen, MD, Peter-John Wormald, ProfAdelaide, SA Australia

Objectives/Hypothesis: To detail the outcomes of primary, revision andendoscopic modified Lothrop (EMLP) (Draf 3)frontal sinus surgery and evaluate whether riskfactors would help determine which patientswould benefit from which procedures

Study Design: Retrospective Cohort study

Level of Evidence: Level 4

Methods: Retrospective chart review. Endoscopic assess-ment of frontal ostium patency and patientreported symptoms were prospectively collect-ed on patients who underwent frontal sinusoto-my between January 2003 and December2009. High risk cohorts were studied to assesstheir response to standard ESS compared withEMLP.

Results: 339 patients underwent either primary or revi-sion endoscopic frontal sinus surgery who metthe inclusion and exclusion criteria. The aver-age length of follow up was 20.8 months (95%CI 18. -22.9 months, SD 18.7 months). Postsurgical recurrence of disease with persistenceof symptoms requiring an EMLP occurred in 9patients in the primary group and 38 in the revi-sion group. The highest risk groups for failure ofstandard frontal sinusotomy were patients withnasal polyps, asthma, Lund Mackay score >16and frontal ostium size <4mm. (Relative risk9.9, P<0.0001).

Conclusions: Patients with underlying asthma and polyposisas well as narrow frontal ostia and extensiveradiological disease have a high failure ratefrom standard endoscopic frontal sinusotomy. Inthis patient group consideration should be givento offering the patient a primary EMLP proce-dure, which has excellent success rates withlow risks and morbidity.


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4:15 PMCombined ARS-AAOA Panel DiscussionEntopy: Local IgE Production in SinonasalDisease

Moderator: David Osguthorpe, MD

Panelists: Testing for Th2-Mediated Nasal Inflammationand Local IgE Production - Bill Reisacher,MDLocal IgE Production in Polyps - RodneySchlosser, MD Local IgE Production in Fungal Sinusitis -Sarah Wise, MD

5:00 PMMeeting adjourned

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Basic & TranslationalResearch SessionSeptember 8, 2012Constitution B

1:00 PMIntroduction - Noam Cohen, MD (Chair, ARSResearch Committee)

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Moderators: Greg Davis, MD & NathanSautter, MD

1:05 PMThe Role of the Inflammasome in CigaretteSmoke Induced RhinosinusitisMurugappan Ramanathan, MD, Thomas E.Sussan, PhD, Tomefa Asempa, BS, ShyamBiswal, PhDBaltimore, MD USA

Introduction: Chronic cigarette smoke (CS) exposure cancause chronic inflammation of the nose andsinuses. The innate immune inflammasomehas gained recent attention as a potentialinflammatory regulator of oxidative insults suchas CS. Previous studies have not examinedthe inflammasome's ability to regulate chronicCS induced sinonasal inflammation and antioxi-dant production.

Methods: Wild type (WT) (n=5) and Caspase-1 knock out(Casp-1-/-, deficient in the inflammasome)C56BL/6 mice (n=5) were exposed to CS viawhole body inhalation daily for 8 months.Control WT (n=5) and Casp-1-/- mice (n=5)were exposed to air. Nasal lavages wereexamined for cellular inflammation followed byhistopathologic analysis of the sinonasalmucosa. Additionally, sinonasal mucosa washarvested and mRNA was isolated for RT-PCRanalysis of proinflammatory cytokines and Nrf2regulated antioxidant genes.

Results: On average, inflammasome deficient micechronically exposed to CS had increased nasallavage eosinophilia and sinonasal epithelial

thickening on histologic sections when com-pared to WT mice exposed to CS. These micealso had an increase in the proinflammatorycytokine IL-6 along with a concurrent decreasein the Nrf2 regulated antioxidant gene NQ01when compared to CS exposed WT mice.

Conclusions: These results suggest that the inflammasomemay regulate CS induced oxidative stress relat-ed sinonasal inflammation in mice. A betterunderstanding of how this innate immune regu-lator of the inflammatory response may lead tomore effective therapies against environmental-ly mediated oxidative stress related sinonasalinflammation.

1:11 PMOlfactory Function in a Porcine Model ofCystic FibrosisEugene H Chang, MD, Tanner J Wallen, BSIowa City, IA USA

Rationale: Humans with cystic fibrosis (CF) often have adecreased sense of smell (hyposmia). It isunknown if hyposmia in CF is due to a primaryloss of the cystic fibrosis transmembrane con-ductance regulator (CFTR) or a secondary con-sequence of nasal polyposis and chronic infec-tion.

Objective: To study if CFTR is necessary for olfaction, weexamined the olfactory epithelia and responseto odorants in a porcine CF model.

Methods: We investigated the ultrastructure of the olfacto-ry epithelia of newborn CF and non-CF pigs byelectron microscopy. We adapted the electro-olfactogram (EOG) to measure voltage changesacross the olfactory epithelia in response toodorant stimuli.

Results: Newborn porcine ethmoid epithelia had well-developed olfactory epithelia. Newborn CF pigshad consistent responses to odorant stimuli byEOG that were not significantly different to theirwild-type littermates.

Conclusions: These results suggest that CFTR is not critical


in the development of the olfactory system.Further studies are needed to investigate ifCFTR is important in the maintenance and mat-uration of the olfactory system. The pig is apotential model to test neural conduction toolfactory stimuli.

1:17 PMThe Predictive Value of the Bitter TasteReceptor T2R38 Genotype for PatientsRequiring Primary Endoscopic SinusSurgery for Chronic RhinosinusitisNithin D Adappa, MD, James N Palmer, MD,Timothy J Howland, MS, Doghramji Laurel, RN,BSN, Robert J Lee, PhD, Noam A Cohen, MD, PhDPhiladelphia, PA USA

Background: The bitter taste receptor T2R38 was recentlydescribed to regulate upper airway innatedefenses through nitric oxide production andincreased ciliary function in response to microbialquorum sensing molecules. Further investigationdemonstrated that the vigorousness of thesedefenses is modulated by polymorphisms withinT2R38, which also confers taste perception tothe molecule PTC. Based on this phenotype,individuals are broadly divided into supertasters,tasters (heterozygotes), and nontasters.

Objective: To determine whether T2R38 genotype predictsthe necessity for surgical intervention for pri-mary chronic rhinosinusitis.

Methods: We performed a retrospective review of patientswho had undergone primary sinonasal surgeryat the University of Pennsylvania and had beengenotyped for T2R38 bitter taste receptor.

Results: Twenty-nine patients were identified who hadprimary sinus surgery with T2R38 genotypesavailable at the time of abstract submission.One patient was a supertaster (3%), fifteenwere heterozygotes (52%) and thirteen werenon-tasters (45%) with general populationgenotype distribution being 20%, 50%, and30% respectively. The lack of supertastersrequiring surgical intervention compared to thegeneral population was statistically significant(p<0.05).

Conclusion: This pilot study demonstrates a statistically sig-nificant deviation from the general population ofT2R38 genotypes. In concordance withincreased innate defense demonstrated by thesupertaster genotype, we demonstrate thatthese patients are less likely to have chronicrhinosinusitis that fails medical therapy andnecessitates surgical intervention. Ultimately,early genotype identification may aid in patientcounseling regarding clinical response to med-ical therapy and guide decision making withregard to surgical intervention.

1:23 PMPresence of Solitary Chemosensory Cellsand Bitter Taste Transduction in SinonasalMucosaHenry P Barham, MD, Sue C Kinnamon, PhD,Thomas E Finger, PhD, Marco Tizzano, PhD,Todd T Kingdom, MD, Vijay R Ramakrishnan, MDAurora, Colorado USA

Background: Solitary chemosensory cells (SCCs) are poly-morphic cells found within the respiratoryepithelium that respond to many stimuli, includ-ing noxious chemicals and bacterial signalingmolecules. SCCs express all components of thebitter taste transduction pathway including theTAS2R family of G-protein coupled bitter tastereceptors and their downstream signaling effec-tors: alpha-Gustducin, PLCbeta2, and the trans-duction channel, TrpM5. When activated,SCCs incite neurogenic reflexes, resulting inupregulation of local inflammatory pathwaysresulting in dendritic cell recruitment andincreased vascular permeability.

Methods: We used RT-PCR, qPCR, and immunohisto-chemistry on biopsies from human sinonasalmucosa to evaluate the presence, location, anddensity of SCCs in patients with chronic rhinosi-nusitis and controls. We selected four subsites-inferior turbinate, middle turbinate, septum, anduncinate- based on prior rodent studies fromour lab.

Results: RT-PCR consistently demonstrates the pres-ence of mRNA for alpha-Gustducin, PLCbeta2,and TrpM5 in three of four sites (inferior andmiddle turbinates, septum) in 7 control and 17


diseased patients. The uncinate process, how-ever, showed differential expression betweencontrol and diseased populations (p=0.02).Overall, qPCR for alpha-Gustducin and TrpM5was similar between groups. PLCbeta2immunostaining confirmed the presence ofSCCs based on classic morphologic character-istics.

Conclusions: SCCs are located in human sinonasal mucosain functionally relevant areas, as are key pro-teins involved in the bitter taste transductionpathway. These findings carry major implica-tions for inflammatory diseases such as rhinitisand rhinosinusitis, and may provide a mecha-nism for local neurogenic inflammation.


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Moderators: Nithin Adappa, MD & DouglasReh, MD

1:37 PMCD8A Gene Polymorphisms Predict SevereChronic RhinosinusitisSaud Alromaih, MD, Leandra Mfuna-Endam,Yohan Bosse, PhD, Ali Alfilali-Mouhim, PhD, Martin Desrosiers, MDMontreal, QC CANADA

Introduction: A genetic basis to chronic rhinosinusitis (CRS)is postulated, but remains elusive. We haverecently identified low levels of circulating CD8lymphocytes as a frequent finding in severe,refractory CRS. Low circulating levels of CD8lymphocytes secondary to mutations in theCD8a and Tapasin (TAPBP) genes lead toMHC-1 deficiency which is associated withsevere CRS.

Obiectives: We wish to identify genetic factors associatedwith MHCI deficiency in CRS.

Methods: Previous results from a genome-wide associa-tion study of chronic rhinosinusitis (Bosse,2009) were screened for polymorphisms in theCD8a and TAPBP genes. Significant polymor-

phisms were screened for associations withdemographic factors characterizing severesinusitis.

Results: The CD8a SNP rs3810831 and TAPBP SNPrs2282851 were significantly associated withCRS. Homozygosity for rs3810831 (CD8a) wasassociated with a higher frequency of affectedrelatives (p=0.042), increased severity as char-acterized by age at diagnosis (p=0.0009),, ageat 1st surgery (p=0.004),, and number of sur-geries (p=0.008),, while rs2282851 (TAPBP)was associated with mild disease (OR= 2.48,p= 0.0076)

Conclusion: Modified CD8a or TAPBP gene function maycontribute to the development of refractory CRSvia altered MHC-1 function and reduction of cir-culating CD8 lymphocytes.

Significance: Identification of markers in the CD8 or TAPBPgenes via sequencing may offer a basis forgenetic testing in CRS.

1:43 PMGene Expression Differences in ReactiveOxygen Species Regulation Point to anAltered Innate Immune Response in ChronicRhinosinusitisCamille R Jardeleza, MD, Damien Jones, BSc,Dijana Miljkovic, BBtech, Neil Tan, MBBS,Sarah Vreugde, MD, Peter-John Wormald, MDAdelaide, South Australia

Background: The complex interplay between host, environ-ment and microbe in the aetiopathogenesis ofchronic rhinosinusitis (CRS) remains to be com-pletely described. This study focuses on thehost-microbe interaction, specifically the regula-tion of nitric oxide (NO) and reactive oxygenspecies (ROS) against the pathogenic organismStaphylococcus aureus (S. aureus). NO andROS play crucial roles in innate immunity andin the first line defense against microbial inva-sion.

Methodology: Sinonasal tissue samples were harvested fromCRS and control patients during surgery. CRSpatients were classified S. aureus biofilm posi-


tive (B+) or negative (B-) using Fluorescence insitu hybridization and clinically as polyp positive(P+) or negative (P-). Samples were assessedusing a Nitric oxide PCR array containing 84genes involved in NO and ROS regulation andgene expression of all sub-groups were com-pared to each other.

Results: 23 samples were included with the greatestgene changes seen in the B+P+ CRS patients.Consistently altered genes based on biofilmand polyp status included the cytoprotectiveOXR1 (Oxidation Resistance 1) and PRDX6(Peroxiredoxin 6), NCF2 (Neutrophil cytosolicfactor 2), and the PRNP (Prion Protein) gene.

Conclusion: Alterations in gene expression point to impairedinnate immune responses differing among CRSsub-groups based on S. aureus biofilm andpolyp status. This demonstrates that CRS is aspectrum rather than a single disease entitywith suggestion that S. aureus biofilm presencealters gene expression. Further studies arerequired to validate these findings in a widercohort of patients and correlate this to proteinexpression and disease manifestation.

1:49 PMA Gene Pathway Analysis of DifferentialExpression in AFRSKibwei A McKinney, MD, Adam M Zanation, MD,Brian D Thorp, MD, Austin Rose, MD, Rounak BRawal, BS, Charles S. Ebert, MD, MPHChapel Hill, NC USA

Introduction: There is a subset of patients with allergic fungalrhinosinusitis (AFRS) with unilateral disease andpreservation of normal sinonasal anatomy on thecontralateral side. Not much is known about thepathophysiologic factors that predispose patientsto unilateral versus bilateral disease.

Objective: To determine whether there is differentialexpression of inflammatory pathways betweendiseased and non-diseased mucosa of patientswith AFRS.

Study Design: Patient-matched analysis of global gene signa-ture profiles and immune system pathways.

Methods: 16 Patients with documented 5/5 Bent-KuhnAFRS criteria were included. Paired samples ofethmoid mucosa were harvested from the dis-eased and non-diseased sides of patients withunilateral AFRS (n=3) and were compared tosamples from bilateral AFRS (n=13) and normalcontrols (n=5). RNA was hybridized to 4x44Kmicroarray chips. A Gene Pathway Analysis ofdifferential expression was performed on 15immune system pathways from the KyotoEncyclopedia of Genes and Genomes (KEGG),at a significance level of p<0.05.

Results: Thirteen of the 15 pathways assessed showedstatistically significant differential expressionbetween diseased and non-diseased samplesof unilateral AFRS patients. Among these werethe pathways for Toll-like receptor signaling,complement cascade, natural killer cell-mediat-ed cytotoxicity, antigen processing and presen-tation, and the T- and B- cell receptor signaling.

Conclusions:There are distinct differences in expression ofimmune pathways in patients with unilateralAFRS. Further elucidation of individual effectorswill be critical in further defining the pathophysi-ology of this disease process.

1:55 PMMatrix Metalloproteinase-9 Gene Regulationin Chronic Rhinosinusitis-associatedOsteitisKara Y Detwiller, MD, Timothy L Smith, MD,MPH, Jess C Mace, MPH, Dennis R Trune,PhD, MBA, Nathan B Sautter, MDPortland, Oregon USA

Objective: Chronic sinonasal inflammation is associatedwith tissue remodeling processes such asosteitis that may be a marker of refractory dis-ease, however, the molecular pathophysiologyof osteitis in chronic rhinosinusitis (CRS) isinsufficiently understood.

Methods: Ethmoid mucosa and bone samples wereobtained from 35 medically refractory CRSpatients and 9 healthy controls. All CRSpatients were treated with standard periopera-tive oral and topical corticosteroids prior to tis-


sue sampling. Quantitative real time poly-merase chain reaction (RT-PCR) was per-formed separately on bone and mucosa forMatrix Metalloproteinase-9 (MMP9). Osteitiswas classified as mild (>3mm), moderate (4-5mm), or severe (>5mm) by measuring bonethickness of the maxillary, sphenoid, and eth-moid sinuses on multiplanar CT. Patients werestratified according to severity of radiographicosteitis and compared to controls.

Results: 9 patients demonstrated radiographic evidenceof osteitis (mild=3, moderate/severe=6). Despiteconcurrent steroid therapy, bone PCR revealedbiologically significant upregulation of MMP9 inall CRS patients, but the magnitude of upregu-lation decreased with severity of radiographicosteitis. Mucosa PCR showed biologically sig-nificant upregulation of MMP9 inmoderate/severe osteitis only.

Conclusion: This is the first study to evaluate the role ofMMP9 in CRS patients with sinonasal osteitis.The pattern of expression suggests there maybe a time and tissue dependent role for MMP9in the pathophysiology of osteitis. In addition,MMP9 overexpression is observed despite pre-operative oral and intranasal steroid use, sug-gesting that MMP9 regulation may not be com-pletely steroid responsive.


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Moderators: Richard Orlandi, MD, DavidPoetker, MD

2:09 PMRegulation of Inflammation-associatedOlfactory Dysfunction by the Type II TNFReceptorPresented by Jonathan Liang, MDAndrew P. Lane, MD, Tatyana Pozharskaya, BA,Jonathan Liang, MDBaltimore, MD USA

Objectives: Olfactory loss is a debilitating symptom ofchronic rhinosinusitis. To study the impact ofinflammation on the olfactory system, theInducible Olfactory Inflammation (IOI) trans-

genic mouse was created in which inflammationcan be reversibly induced within the olfactoryepithelium. In this study, the type II TNF recep-tor (TNFR2) was knocked out, and the effect onthe olfactory loss phenotype was assessed.

Methods: IOI mice were bred to TNFR2 knockout mice toyield progeny IOI mice lacking the TNFR2receptor (TNFR2KO). TNF-alpha expressionwas induced within the olfactory epithelium for6 weeks to generate chronic inflammation.Olfactory function was assayed by electro-olfac-togram (EOG), and olfactory tissue wasprocessed for histology and immunohistochemi-cal staining.

Results: Compared to IOI mice with wild type TNFR2,IOI mice lacking the TNFR2 demonstrated simi-lar levels of inflammatory infiltration andenlargement of the subepithelial layer.However, IOI-TNFR2KO mice differed markedlyin that the neuronal layer was largely preservedand active progenitor cell proliferation was pres-ent. Odorant responses were maintained in theIOI-TNFR2KO mice, in contrast to IOI mice.

Conclusions: TNFR2 is the minor receptor for TNF-alpha, butappears to play an important role in mediatingTNF-induced disruption of the olfactory system.This finding suggests that neuronal death andinhibition of proliferation in CRS may be mediat-ed by TNFR2 on olfactory neurons and progeni-tor cells. Further studies are needed to eluci-date the subcellular pathways involved anddevelop novel therapies for treating olfactoryloss in the setting of CRS.

2:15 PMEvaluation of mmp-9 and timp-1 Levels ofthe Patients with Nasal Polyposis afterCorticosteroid TherapiesDogan Pinar, MD, Hakan Cincik, MD, EvrenErkul, MD, Osman Metin Ipcioglu, MD, Engin Cekin, MD, Atila Gungor, MDIstanbul, NA Turkey

Objective: The aim of this study is to evaluate the effectsof intrapolyp, systemic and local corticosteroidtreatment modalities on MMP-9 and TIMP-1level in polyp tissues.


Study Design: Prospective, controlled study.

Setting: Tertiary Training Hospital

Subjects and Methods: This study included 57 patients with nasal poly-posis and 14 patients with concha bullosa.Group A treated with oral methylprednisolone,Group B treated with topical steroid spray,Group C treated with intralesional triamcinoloneacetonid. Group D did not receive any medica-tion. Group E had surgery for concha bullosawithout nasal polyp disease. Tissue Samplesfrom the groups were collected and, MMP-9and TIMP-1 levels were measured by Enzyme-Linked Immunosorbent Assay method.

Results: Mean MMP-9 levels of the groups were 57.29,89.99, 49.31, 63.91 and 70 mcg/gr proteinrespectively. There were no significant differ-ences among the groups regarding MMP-9 lev-els. Mean TIMP-1 levels of the groups were52.21, 57.52, 32.32, 48.28 and 84.94mcg/grprotein respectively. There was significant dif-ference of TIMP-1 level between groups C andE (pC-E=0,0019), however there was no differ-ence among the level of the other groups.When MMP-9/TIMP1 rates of all groups werecompared, there were significant differencebetween group A and D (pA-D=0,005) andbetween group A and E, also between group Cand E.

Conclusion: Our study is the first study to evaluate theeffects of different corticosteroid treatmentmodalities on MMP-9 and TIMP-1 levels innasal polyps and concluded that corticosteroiddid not do a significant impact on this pathway.

2:21 PM Corticosteroid Sensitivity of EpithelialMDR1/P-gp in Chronic Sinusitis with NasalPolypsBenjamin S Bleier, MD, Rachel Feldman, BABoston, MA USA

Introduction: P-glycoprotein(P-gp) is a 170kDa transmem-brane glycoprotein encoded by theMDR1(ABCB1) gene. Recent studies haverevealed that P-gp can function as a cytokine

efflux pump in a variety of tissues and is upreg-ulated in chronic sinusitis with nasalpolyps(CRSwNP). Corticosteroid exposure hasbeen shown to downregulate lower airway P-gpexpression thereby resulting in a reduction in P-gp mediated cytokine secretion. The purpose ofthis study is to therefore determine whetherepithelial P-gp expression in CRSwNP is simi-larly sensitive to corticosteroid exposure.

Methods: IRB approved study utilizing nasal polyp tissue in18 patients with CRSwNP. Nine patients weresteroid naïve and nine were treated with 40mg ofprednisone daily for 1 week prior to tissue sam-pling. Quantitative fluorescent immunohisto-chemistry(Q-FIHC) was performed using an anti-P-gp antibody and a secondary FITC conjugatedFc specific fragment. Protein expression wasquantified by calculating the epithelial to nonspe-cific background intensity ratio. Scores less than1 suggested negligible expression. Stainingratios between patient groups were comparedusing a 2-tailed Student's t-test.

Results: Among the steroid naïve patients, P-gp stainingratios in the polyp epithelium were elevatedcommensurate with prior studies(1.556+/-0.365). There was no significant differencefound in the steroid exposed group(1.333+/-1.172, p=NS).

Conclusions: MDR1/P-gp expression in nasal polyps is notsignificantly reduced in the setting of corticos-teroid exposure differing from findings seen inthe lower airway. This data suggests that theoverexpression of P-gp in nasal polyps coupledwith its corticosteroid insensitivity may play arole in the pathogenesis of the CRSwNP.

2:27 PMRoles of Dual NADPH Oxidases in ChronicRhinosinusitisDo-Yeon Cho, MD, Dawn Bravo, PhD, JayakarV Nayak, MD, PhD, Peter H Hwang, MD, BeateIllek, PhD, Horst Fischer, PhDStanford, CA USA

Introduction: The airway epithelium generates reactive oxy-gen species (ROS) as the first line of innatedefense. Physiologic balance between ROS


production and rate of their elimination protectsagainst oxidative cell injury. Dual oxidases(DUOX1 and DUOX2) are the H2O2-producingisoforms of NADPH oxidase family found in air-way epithelium. The purpose of this study wasto identify the molecular expression and func-tion of DUOXs in chronic rhinosinusitis (CRS).

Methods: Human nasal tissue and secretion were collect-ed from three groups (normal, CRS with andwithout polyposis). Luminex cytokine assayand Amplex-Red H2O2 assay of nasal secre-tion were performed as well as immunofluores-cence microscopy and qPCR (DUOX1 andDUOX2) of nasal tissue.

Results: Significantly higher levels of IL-2, IL- 4, IL-8were detected in CRS with and without polypo-sis compared to normal (p=0.018, 0.049, 0.023,respectively). mRNA expression for DUOX1(80.7±60.5) was significantly higher in CRS withnasal polyposis compared to normal (2.7±1.2)and CRS (2.3±0.5) (p=0.042). CRS with(18.6±9.9) and without polyposis (4.0±1.3) hadstatistically higher DUOX2 expression, com-pared to normal (1.1±0.3; p=0.008).Immunohistochemistry staining of DUOX wasobserved in the apical portion of epithelium.H2O2-production was significantly higher inCRS with (114.6±33.4 NRFU) and without poly-posis (100.4±13.1) compared to normal(67.1±3.0) (p=0.03).

Conclusions: Key inflammatory cytokines were found to beup-regulated in CRS. Both DUOX1 and DUOX2were up-regulated in CRS with polyposis andDUOX2 was up-regulated in CRS without poly-posis. DUOX proteins were expressed in nasalepithelium and may play an important role inROS production and pathogenesis in CRS.


2:41 PMBreak with Exhibitors - Constitution C

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Moderators: Eric Holbrook, MD, VijayRamakrishnan, MD

3:10 PMSinonasal Epithelial Wound Resealing in anin Vitro Model: Inhibition of Wound Closurewith IL-4 ExposureSarah K Wise, MD, Kyle A DenBeste, BS,Elizabeth K Hoddeson, MD, Charles A Parkos,MD, PhD, Asma Nusrat, MDAtlanta, GA USA

Introduction: Prolonged healing and persistent inflammationfollowing surgery for rhinosinusitis impactpatient satisfaction and healthcare resources.Cytokines interleukin (IL)-4, 5, and 13 areimportant mediators in Th2 inflammatory rhinos-inusitis. Decreased wound healing has beendemonstrated with Th2 cytokine exposure, butthis is not extensively studied in sinonasalepithelium. We hypothesized that in vitro expo-sure of primary sinonasal epithelial cell culturesto characteristic Th2 inflammatory cytokine IL-4and IL-13 will impair wound resealing anddecrease expression of epithelial migratory pro-tein annexin 2 at the wound edge.

Methods:Following 24-hour exposure to IL-4, 5, or 13

versus controls, sterile linear mechanicalwounds were created in primary sinonasalepithelial cultures (n = 12 wounds per condi-tion). Wounds were followed for 36 hours oruntil complete closure and wound areas calcu-lated by image analysis. Group differences inepithelial migratory protein annexin 2 wereassessed by immunofluorescence labeling, con-focal microscopy, and Western blots.

Results: Significant wound closure differences were iden-tified across cytokine exposure groups(p<0.001). At 36-hours, 75% of wounds exposedto IL-4 were incompletely closed, whereas only25% of control wounds remained open. IL-13 didnot significantly impair sinonasal epithelial woundresealing in vitro. With IL-4 exposure, woundedge annexin 2 was decreased versus no-cytokine exposure control (p<0.01).

Conclusions: Th2 cytokine IL-4 decreases sinonasal epithe-lial wound closure in vitro. Wound edge annexin2 is also diminished with IL-4 exposure. This


supports the hypothesis that IL-4 exposureimpairs sinonasal epithelial wound healing andmay contribute to prolonged healing in Th2inflammatory rhinosinusitis.

3:16 PMCigarette Smoke Inhibits Nasal AirwayEpithelial Cell Growth and SurvivalJean Kim, MD PhD, Hyun S Lee, PhDBaltimore, MD USA

Introduction: Second hand smoke (SHS) exposure has beenshown to be highly associated with chronic rhi-nosinusitis (CRS). We hypothesized that nasalepithelial cell growth from healthy human sub-jects is dependent on vascular endothelialgrowth factor (VEGF) and that SHS results inimpairment of cell growth and survival neces-sary for normal epithelial cell function. To studythis, we examined whether epithelial cell growthis dependent upon VEGF. We also examinedthe effect of cigarette smoke extract (CSE)exposure to functionally inhibit human primarynasal epithelial cell (PNEC) growth and induceapoptosis of PNEC.

Methods: Human PNEC from normal control subjectswere cultured to sub-confluence under sub-merged conditions. Cell growth was assessedusing a proliferation assay. Apoptosis wasassessed using flow cytometric analysis ofannexin V-FITC.

Results: Exposure of PNEC from normal healthy controlsubjects to VEGF receptor blocking antibodyagainst NP1 resulted in inhibition of constitutivecell growth. CSE exposure resulted in dose-dependent inhibition of constitutive nasalepithelial cell growth. CSE exposure also result-ed induction of annexin V-FITC staining in adose-dependent manner, comparable to thatseen with VEGF blockade using anti-NP1 anti-body.

Conclusions: PNEC from normal healthy control subjects dis-play VEGF-dependent constitutive cell growth.CSE impairs cell growth and promotes apopto-sis of normal healthy nasal epithelial cells,thereby contributing to epithelial cell dysfunctionin CRS.

3:22 PMAzithromycin and Simvastatin Reduce IL-6Secretion in an Epithelial Cell Model ofChronic RhinosinusitisMarie Devars du Mayne, MD, Valérie Tardif, MSC,Leandra Mfuna, MSc, Martin Desrosiers, MDMontreal, Quebec Canada

Aims:In chronic rhinosinsusitis (CRS) corticosteroidsremain the gold standard of therapy. However,as in asthma, a percentage of patients havedisease unresponsive to steroids and alternateanti-inflammatory agents may be required.Azithromycin (AZI) suppresses NF?B activation,downstream pro-inflammatory cytokines andhas been used in CRS. Simvastatine (SIMVA)has pleiotropic anti-inflammatory effects andmay also be of benefit in CRS. We wished toassess the anti-inflammatory actions of AZI andSIMVA on epithelial cells in an in-vitro model ofCRS.

Methods: Primary epithelial cell cultures were raised fromsinus mucosa obtained from CRS patients attime of ESS and raised until differentiated in anair-liquid interface. Cells were incubated in thepresence of medium, AZI (10 et 50 µg/mL) andSIMVA (5 µg/mL). Cytokine generation wasassessed by measurement of IL-6 by ELISA.(n=6 patients)

Results: Incubation with both AZI and SIMVA gavereduced IL-6 levels, with SIMVA having thegreatest effect. (MED: 278.2 pg/mL, AZI10µg/mL: 232,7 pg/mL; AZI 50µg/mL: 219.9pg/mL; SIMVA : 63.7 pg/mL, p=0.01)

Conclusion: These results confirm an anti-inflammatoryeffect of AZI and SIMVA on epithelial cells inthis ex-vivo model of CRS.

Implications: These agents may have potential roles as anti-inflammatory agents in patients with CRS unre-sponsive to usual therapy. These early ex-vivoresults should nevertheless be confirmed byassessment on organotypic ex-vivo models andin CRS subjects prior to adoption in clinicalpractice.

3:28 PM


Damage-associated Molecular PatternsStimulate IL-33 Expression in Nasal PolypEpithelial CellsAndrew Lane, MD, Gina Paris, BA, Jonathan Liang, MDBaltimore, MD USA

Objectives: Chronic rhinosinusitis with nasal polyps(CRSwNP) is a disorder characterized byeosinophilic inflammation and local Th2cytokine production. Innate lymphoid cells thatelaborate Th2 cytokines have recently beencharacterized within nasal polyps. These cellscan be activated by the epithelial cell-derivedcytokine IL-33. In this study, we demonstratethat molecules associated with tissue damage(DAMPs) elicit expression of IL-33 in sinonasalepithelial cells (SNEC) derived from recalcitrantnasal polyposis patients.

Methods: SNEC were obtained from 14 patients duringESS from patients with nasal polyposis. Thesubjects were subsequently followed for greaterthan 6 months and classified with respect toendoscopic recurrence or persistence of polyps.SNEC were grown in culture at the air-liquidinterface and exposed to DAMPs for 48 hours.Cells were processed for either mRNA extrac-tion or immunochemistry. IL33 levels weredetermined by real-time PCR and by immuno-chemical staining with anti-IL-33 antibody.

Results: Exposure to HMBG1 or ATP resulted in a statis-tically significant increase in IL-33 mRNAexpression in SNEC derived from patients withrecalcitrant polyps. This increase was reflectedat the protein level by immunochemical stain-ing of IL-33.

Conclusion: Tissue damage is a non-specific trigger ofepithelial IL-33 production in treatment-recalci-trant polyps, which may be responsible for per-petuating eosinophilic inflammation in CRSwNP.This common pathway may help explain whymultiple environmental and infectious agentshave been implicated in association withCRSwNP exacerbation.


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Moderators: Devyani Lal, MD, Ameet Singh, MD

3:42 PMNon-invasive Staphylococcus AureusBiofilm Determination in ChronicRhinosinusitis by Detecting theExopolysaccharide Matrix Component Poly-N-acetylglucosamineAndrew Foreman, MD, PhD, Joshua Jervis-Bardy, MD, Samuel Boase, MD, Peter-John Wormald, MDWoodville, SA Australia

Introduction: The role that bacterial biofilms might play inrecalcitrant forms of CRS is increasingly beingrecognized. However the detection of bacteriaexisting in this form, using standard culture, islimited by their unique metabolically inactiveproperties. All current biofilm diagnostic modali-ties require invasive mucosal biopsies, whichlimit their use to the operating theatre.

Method:20 CRS patients and 5 controls were enrolled ina prospective study to assess the feasibility ofnon-invasively diagnosing S. aureus biofilms bydetecting the biofilm matrix polysaccharidepoly-N-acetylglucosamine (PNAG). An immuno-fluorescence protocol was developed for PNAGdetection and compared with both standardmicrobiological cultures and FISH.

Results: 13/20 CRS patients had evidence of S. aureusbiofilm formation using FISH. Of these, 12 haddetectable PNAG. Interestingly none of the S.aureus FISH negative patients were PNAG pos-itive despite the presence of coagulase nega-tive Staphylococci biofilms, some of which mayexhibit PNAG in their pathogenic forms.

Discussion:The development of a non-invasive S. aureusbiofilm diagnostic test provides a reliable meansto identify a high-risk group of CRS patientswho harbor S. aureus biofilms. The ability to uti-lize outside of the peri-operative period toassess surgical efficacy, guide management


and evaluate new treatment modalities providesa significant advance in this field of researchand clinical practice.

Conclusions: This study has confirmed the feasibility of non-invasive detection of S. aureus biofilms with asimple test that produces comparable resultswith the more invasive methods that are cur-rently relied upon.

3:48 PMIntracellular Staphylococcus Aureus: TheTrojan Horse of Recalcitrant ChronicRhinosinusitis?Neil C-W Tan, MBBS, MRCS, AndrewForeman, MBBS, PhD, Camille Jardeleza,MBBS, Richard Douglas, MBChB, FRACS,Sarah Vreugde, MBBS, PhD, Peter-JohnWormald, MD, FRACSAdelaide, SA Australia

Introduction: Despite recent evidence suggesting thatStaphylococcus aureus exists within the sino-nasal epithelium of chronic rhinosinusitis (CRS)patients, the true clinical significance had notbeen defined. The intracellular environment mayprovide a protective niche for pathogenic bacte-ria to evade host immunity and yet provide areservoir for re-infection. To date, no studieshave examined the impact of this bacterial phe-notype; therefore this study was designed toevaluate the role of intracellular S. aureus onpost-surgical outcomes.

Methods: This prospective study included fifty-six patientsundergoing endoscopic sinus surgery for med-ically-recalcitrant CRS. Sinonasal mucosa har-vested at the time of surgery was dually stainedwith fluorescent molecular probes and imagedusing Confocal Scanning Laser Microscopy forbiofilm and intracellular status. Patients werefollowed-up in their early and late postoperativecourse for evidence of on-going disease andsigns of clinical relapse.

Results: Intracellular S. aureus was identified in 23/56(41%) patients, and all were associated withsurface biofilm. Biofilm alone was found 16(29%) patients and 17 (30%) patients had noevidence of organisms. Intracellular positive

patients had a significantly higher risk of laterelapse (p=0.037) and persistence of bacteriathroughout the postoperative course(p=0.0445). In this study, biofilm status withoutco-existing intracellular bacteria did not appearto impact on outcomes.

Conclusions: Relapse of disease following ESS is significant-ly associated with intracellular S. aureus.Evidence suggests that this disease phenotypeis an independent risk factor to surface biofilmstatus. Novel treatment modalities must bedeveloped to target the intracellular bacteriathemselves.

3:54 PMNeutrophilic Inflammation on SinusCytology is Associated with Poor Responseto Standard Therapy in Post-ESS PatientsSawsan Al-Mot, BScMontreal, Quebec Canada

Objectives: We have described an in-vitro expression signa-ture for CRS (Desrosiers, 2011) suggesting pat-terns of high- and low- neutrophilic inflammationin CRS. We wished to determine whether mini-mally-invasive cytology brushing of the sinusmucosa could be used to characterise sinusmucosal immunity in-vivo in CRS, and evaluatewhether it influences disease evolution.

Method: A gastric cytology brush was used to samplethe frontal recess in 8 control subjects and 33post-ESS CRS patients (11 good-evolution; 22bad-evolution). Cytologies were prepared andstained for neutrophil elastase (NE) using IHC.Neutrophilia was characterized as intensity ofNE staining on a scale of 1 - 5. Results wereassessed using receiver-operating characteris-tic (ROC) analysis and Spearman's rank analy-sis to compare groups.

Result: Neutrophil level was high in both CRSwNP andCRSsNP, with no difference between the twoCRS groups. ROC analysis identified that a cut-off point at 2 on a 5-point scale predicted CRS(sensitivity: 74%; specificity: 80%). When strati-fied according to disease evolution, neutrophiliawas high only in the poor-evolution CRS sub-group (p=0.000012)


Conclusion: Sinus cytology can identify neutrophilic inflam-mation at the sinus mucosa level in post-ESSpatients, using a simple, minimally-invasivesampling technique that can be performed inclinic. Identification of high neutrophilia in onlypost-ESS persistent disease suggests that pre-viously described high-neutrophilic inflammationexpression signatures in CRS may be associat-ed with a more severe, steroid-insensitive formof CRS. Sinus cytology may identify refractoryCRS cases requiring alternate anti-inflammatorytreatments.

4:00 PMThe Characteristics of Intramucosal Bacteriain Chronic Rhinosinusitis (CRS).Raymond Kim, MD, Sally Roberts, MD, JoshuaFreeman, MD, Richard Douglas, MDAuckland, AKL New Zealand

Introduction: We have observed intraepithelial and interstitialbacterial microcolonies within the mucosa ofpatients with CRS. The remarkable feature ofthe intramucosal microcolonies, predominantlyStaphylococcus aureus, is that they do not elicitan inflammatory response. We hypothesizedthat these microcolonies are metabolically dif-ferent from planktonic bacteria, rendering themless immunogenic. We have sought to charac-terize the nature of the intramucosal colonies.

Methods: Mucosal swabs, and tissue biopsies were takenfrom 45 patients with CRS and 13 with normalsinuses having transnasal pituitary surgery.Strains of S aureus were compared via pulsefield gel electrophoresis, if cultured from bothswab and tissue. Small colony variants (SCVs)of S aureus were attempted to be cultured.SCVs are metabolically atypical forms that tendto be antibiotic resistant and produce fewer viru-lence factors than wild-type. Accessory generegulator (agr) gene activity was deduced byassessing the hemolysis around colonies onblood agar plates. agr controls the activity ofmany of S aureus virulence factors, and hemoly-sis has been found to correlate with agr activity.

Results: S aureus were of the same strain in all cases,when cultured from both swab and mucosa.SCVs were grown in 2 samples, but both were of

non-S aureus staphylococcal species. All Saureus cultured from tissue samples were ß-hemolytic, suggesting normal agr activity.

Conclusion: These studies suggest that intramucosal Saureus are genetically closely related and phe-notypically similar to surface S aureus. Furtherstudies are needed to explore the possiblemechanisms by which intramucosal coloniesbecome less immunogenic.


____________________________________

4:15 PMEvolution in Action: Changing Views on theContribution of Microbes to CRS

Moderator: Noam Cohen, MD

Panelists: Martin Desrosiers, MD - Dysbiosis of theSinus Microbiome on Local ImmuneResponses in CRSPeter John Wormald, MD - Staph Aureus andits Role in CRSNoam Cohen, MD - Genetic Susceptibility toGram-Negative Sinonasal Infection and CRS

5:00 PMMeeting adjourned


Poster# P-1A Comparative Assessment of the PatientEducation Resources from the AmericanAcademy of Otolaryngology-Head and NeckSurgery Foundation (AAO-HNSF) andAmerican Rhinologic Society PatientEducation MaterialsNitin Agarwal, BS, David R Hansberry, PhD,Qasim Husain, BS, Saurin Anghvi, BS,Mohemmed N Khan, MD, FACSJean Anderson Eloy, MD, FACSNewark, NJ USA

Introduction:The American Medical Association and NationalInstitutes of Health recommend the readabilityof patient information resources be between 4thand 6th grade levels. The authors compare thereadability of online patient education resourcesprovided by the American Academy ofOtolaryngology-Head and Neck SurgeryFoundation (AAO-HNSF) and AmericanRhinologic Society (ARS) website using nineassessment tools.

Methods: Online patient education resources from theAAO-HNSF and ARS were downloaded inFebruary 2012. Readability assessments wereconducted using the Flesch Reading Ease(FRE), Flesch-Kincaid Grade Level (FKGL),SMOG Grading (SMOG), Coleman-Liau Index(CLI), Gunning-Fog Index (GFI), the RaygorReadability Estimate (RRE), and the Fry Graph.Written text from each website was pasted intoMicrosoft® Word® (Microsoft Corp, Redmond,WA) documents and analyzed using ReadabilityStudio Professional Edition Version 2012.1(Oleander Software, Ltd, Vandalia, Ohio). Themean readability scores from the two websiteswere compared using a Student's t-test.

Results:In total 186 articles were analyzed. All patienteducation resources acquired from the AAO-HNSF were written between an 11th grade andgraduate reading level. ARS resources were writ-ten between a 9th grade and graduate readinglevel. The mean readability scores of the infor-mation from both sources were statistically signif-icant when assessed using FRE (p < 0.05),SMOG (p < 0.05), or GFI (p < 0.01).

Conclusions:AAO-HNSF and ARS online materials were

both considered difficult to read. The readinglevel of each website exceeded the recom-mended sixth grade level, which may warrantrevisions to reach a wider audience andincrease patient comprehension.

Poster# P-2A critical view on the use of nasal casts toassess nasal spray deposition patternsPer G Djupesland, MD, PhDYardley, PA USA

Introduction: Assessment of nasal spray deposition pattern ina commercially available silicone human nasalcast (Koken Co) using a water-indication coatinghas in recent publications been advocated as aquick method to study patient-, device- and for-mulation-related variables. However, the Koken-cast is primarily an educational tool with a flattransparent septum to show the complicatednasal structure. We measured the dimensions ofthe Koken cast and compared them with norma-tive in vivo data and another silicone cast(OptiNose, US Inc.).

Methods: Acoustic rhinometry (AR) was used to measurethe dimensions of the casts and the healthymale individual who served as the model for theOptiNose-cast. The measured minimal cross-sectional area (MCA) describes the dimensionsat the narrowing of the nasal valve; the areathat determines airflow and particle depositionpatterns.

Results:The MCA on right and left sides were; Koken-cast (MCA right/ left=1.95/1.80 cm2); OptiNosecast (MCA right/left=0.69/0.70cm2); in vivo(MCA right/left=0.75/0.56 cm2). Normative ARdata in healthy males are;MCAright/left=0,59±0,19/56±0,13cm2.The ARdimensions of the OptiNose cast and thehealthy individual were very similar (Pearsonr=0.98 and r2=0.96, P>0.0001 for the anterior 6cm)

Conclusions:Largely due to the flat septum of the Koken-cast design, the MCA is 3-4 times larger thatnnormative AR data in healthy individuals and faroutside the normal range. In contrast, theOptiNose-cast dimensions are very similar tothe in vivo AR-normative values. Cast dimen-

Posters


sions should always be reported and airflowand spray deposition data from casts with toolarge dimensions must be interpreted with cau-tion.

Poster# P-3A prospective study of post-operative symp-toms in sinonasal quality-of-life followingendoscopic endonasal non-pituitary skullbase surgeryJeffrey C Bedrosian, MD, Roheen Raithatha,MD, Edward D McCoul, MD, MPH, Vijay KAnand, MD, Theodore H Schwartz, MDNew York, NY USA

Objectives:To better delineate the effect of extended endo-scopic endonasal non-pituitary skull base sur-gery on specific post-operative sinonasal quali-ty-of-life symptoms.

Methods:Thirty-three patients were prospectivelyassessed with the Anterior Skull BaseQuestionnaire (ASBQ) preoperatively and up to1 year postoperatively at each subsequentoffice visit. A subset of these data was ana-lyzed to assess the effect of endoscopic skullbase surgery on post-operative taste, smell,appetite, nasal secretions and vision.

Results:Using the ASBQ, a validated quality-of-lifeinstrument, we prospectively assessed patient-reported symptoms following endoscopicendonasal non-pituitary surgery. Pathologiesincluded chordomas (n=7), craniopharyngiomas(n=6), encephaloceles (n=4), meningiomas(n=4), skull base malignancies (n=3) and others(n=9). Compared to pre-operative scores,patient reported sense of smell was significantlydecreased at 3 weeks and 6 months post-oper-atively (3.11 vs. 2.45, p=0.04 vs. 2.31, p=0.03,respectively). By 1 year, patient-reported senseof smell was no longer significantly decreased(2.7, p=0.77). There were no observed statisti-cally significant changes in patient reportedappetite, taste, nasal secretions or vision duringthe 1 year post-operative follow up period.

Conclusions:Within this diverse set of pathologies, extendedendoscopic endonasal skull base approachesproduced a prolonged post-operative patient-reported decrease in sense of smell. These

results were no longer statistically different by 1year post-operatively. This may, however, bedue to a smaller follow-up group reporting 1year results (n=10). No reported post-operativechanges in appetite, taste, nasal secretions orvision were observed.

Poster# P-4A Simple Method for Endonasal EndoscopicDacryocystorhinostomyMohsen Naraghi, MDTehran, Tehran Iran

Introduction: In this article, author's simple technique onendonasal endoscopic will be presented withresults, mentioning the main advantages of it.

Methods: The maxillary crest was the best landmark inour cases, eliminating the need for light pipe.The mucosa over the sac was elevated by a tri-angular elevator. After exposure of the bonycrest this bone was removed by a sharp punchforceps. After total exposure of the sac, themedial wall of the sac was removed by thesame punch forceps. The opening is made solarge, exposing the lateral wall of sac, observ-ing openings of the canaliculus into the sac inmany cases. The nasal mucosal flap wasincised to laying it over the sac. By the final trimof flap up to the remaining sac wall, fineapproximating of the edges is done. The latterstep is very important in preventing post opera-tive granulation and should be done meticulous-ly. The procedure needs no tenting by lacrimalprobe and no stenting of the lacrimal system.

Results:In follow up of patients, ninety five percent ofpatients free of symptoms. This wide rhinosto-my together with nontraumatic technique avoid-ing mucosal damage and bone exposure at theend of procedure ensures patency in long term.

Conclusion: This simple technique diminishes the expensesof powered or laser instrumentation with com-parable results. It seems that preserving normaltissues and creating a patent rhinostomy withleast surgical trauma and less subsequent scar,plays the most important role to achieve desir-able results.


Poster# P-5Academic rhinology: A survey of otolaryn-gology residency programs in the UnitedStatesAbtin Tabaee, MD, Leon Chen, MD,Madeleine R Schaberg, MD, RoheenRaithatha, MD, Seth M Brown, MD-MBANew York, NY USA

Objectives: The evolution of rhinology as a distinct sub-spe-cialty has significant implications for clinical andacademic medicine. Its impact on residencyprograms remains incompletely defined.

Methods: A survey of faculty profiles of otolaryngologyresidency programs in the United States wasperformed to examine the professional demo-graphics and academic activities of rhinologists.

Results: 9% of chairmen and 12 % of residency programdirectors were rhinologists. The number of full-time rhinology faculty members varied signifi-cantly amongst departments(mean:1,range:0-4). 30% of departments had no full-time rhinolo-gists at the primary training institution.Rhinology faculty members were noted to havea high number of scientific publications over thepast 5 years (mean:15 per faculty, range:0-88).A high level of membership to the AmericanRhinologic Society (90%) and a modest level ofmembership to Triological Society(23%),NASBS(22%), and AAOA(12%) were noted.The presence of a rhinology fellowship in thedepartment and a larger residency size wereassociated with a larger rhinology faculty. Ahigher number of publications per faculty werenoted in programs with rhinology fellowshipsand with multiple rhinology faculty members. Alonger duration of time since completion oftraining was associated with a greater numberof publications, a lower likelihood of completinga fellowship and a higher membership rate inthe Triological Society.

Conclusions: Variability exists in the presence and academicactivities of rhinology faculties in otolaryngologyresidency programs. Continued analysis of theimpact of rhinology sub-specialization on work-force measures and residency education isrequired.

Poster# P-6Assessment of Mucocele Formation afterEndoscopic Nasoseptal Flap Reconstructionof Skull Base DefectsQasim Husain, BS, Saurin Sanghvi, BS, PratikA Shukla, MD, Osamah J Choudhry, MD,James K Liu, MD, Jean Anderson Eloy, MD,FACSNewark, NJ USA

Introduction: Advances in endoscopic skull base surgeryhave led to the resection of increasingly largercranial base lesions, resulting in large skullbase defects. These defects have initially led toincreased postoperative cerebrospinal fluid(CSF) leaks. The development of the vascular-ized pedicled nasoseptal flap (PNSF) has suc-cessfully reduced postoperative CSF leaks.Mucocele formation however, has been report-ed as a complication of this technique. In thisstudy, we analyze the incidence of mucoceleformation following repair of skull base defectsusing a PNSF.

Methods: A retrospective review of a prospective data-base from December 2008 to December 2011was performed to identify patients who under-went PNSF reconstruction for large ventral skullbase defects. Demographic data, defect site,incidence of postoperative CSF leaks and rateof mucocele formation were collected.

Results: Seventy patients undergoing PNSF repair ofskull base defects were identified. No postoper-ative mucocele formation was noted at an aver-age radiological follow-up of 11.7 months(range 3-36.9 months) and clinical follow-up of13.8 months (range, 3-38.9 months), makingthe overall mucocele rate 0%. The postopera-tive CSF leak rate was 2.9%.

Conclusions: Proper closure of skull base defects is crucial toprevent CSF leaks. The PNSF has been provento be an efficient technique for these repairs.Although this flap may carry an inherent risk ofmucocele formation when placed overmucosolized bone during repair, we found thatmeticulous and strategic removal of mucosafrom the site of flap placement resulted in a 0%incidence of postoperative mucocele formationin our cohort.


Poster# P-7Assessment of the short term patency of themaxillary sinus ostium following dilatationwith an osmotic device in a sheep modelJerome E. Hester, MD, David Edgren, BS,Andrea Koreck, MD, PhD, Jason Fox, BSEast Palo Alto, CA USA

Introduction:Establishment of patency of the sinus ostia isparamount to the treatment of chronic sinusitis.Endoscopic sinus surgery has been shown tobe effective in accomplishing this. Recently,catheter based balloon dilation has been intro-duced as an alternative method to open thesinus ostia. The purpose of this investigationwas to explore the feasibility of an osmoticallydriven, self expanding device to dilate the sinusostia in an animal model.

Methods:The devices were placed under endoscopicvision into the maxillary sinus ostia of adultsheep. the devices were removed at pre-deter-mined time points between 4 and 15 hours andmeasurements taken of the diameter of boththe expanded device and the resulting ostia. Ina subset of animals endoscopy was repeated at13 and 27 days after placement.

Results:Initial examination revealed strong correlationbetween the size of the dilated device and theresultant ostia. A smooth bore opening resultedwith no signs of mucosal injury. All ostia werefound to maintain essentially this same dilatedsize at the 27 day follow up examination.

Conclusion:This initial study indicates that this osmoticallydriven self expanding device will dilate in vivoand produce a patent ostia that is maintainedfor at least 27 days. The ease of placementand atraumatic means of dilation make thismechanism an attractive treatment strategy.Additional testing in patients will be needed toconfirm safety and efficacy.

Poster# P-8Atypical Radiographic Presentations ofJuvenile Nasopharyngeal Angiofibroma.Anna Knisely, MD, Carl Snyderman, MD,Carlos Pinheiro-Neto, MD, Eric Wang, MDPittsburgh, PA USA

Objective:To describe nasopharyngeal angiofibroma(JNA) with atypical imaging characteristicsincluding clival erosion in the absence of ptery-gopalatine fossa (PPF) enlargement.

Background:JNA is an uncommon, locally destructive benignnasal neoplasm that classically presents withprogressive nasal obstruction and/or epistaxisin an adolescent male. JNA is thought to arisefrom the sphenopalatine foramen, and mayextend into the nasal cavity, orbit, and cranialfossa. Biopsy of these masses is ill-adviseddue to their intensely vascular nature, thushighlighting the importance of imaging in theaccurate diagnosis of the disease. PPFenlargement is characteristic and has beencited as a constant feature in patients with JNA.The Holman-Miller sign (HMS), anterior dis-placement of posterior wall maxillary sinus isconsidered pathognomonic.

Methods:Pre-operative CT and/or MRI of patients withpathological-proven JNAs were reviewed at asingle institution from 2000-2011. All caseswere reviewed for presence of PPF enlarge-ment, HMS, and clival erosion.

Results: Three out of twenty-two JNAs had atypical radi-ographic presentations, specifically a lack of PPFenlargement or HMS. One JNA involved onlythe nasal cavity and nasopharynx, an uncom-mon, but described pattern. Interestingly, two ofthese three cases demonstrated clival and pos-terior pterygoid involvement, while the overallincidence is significantly less.

Conclusions:The characteristic radiologic findings of PPFenlargement and HMS are present in the major-ity of cases and aid in the diagnosis of JNA,however their absence does not preclude it.Atypical cases may present with clival erosion,making the differentiation between JNA andrhabdomyosarcoma increasingly difficult.


Poster# P-9Balloon catheter dilation in pediatric silentsinus syndrome: a case seriesJackie Matijasec, MD, Kevin McLaughlin, MDNew Orleans, LA USA

Objective: It has been suggested that balloon catheterdilation is less successful in pediatric patientswith hypoplastic maxillary sinus. Our experi-ence has been to the contrary and we describea cohort of pediatric patients with silent sinussyndrome and their treatment with ballooncatheter dilation.

Study Design: Case series.

Methods: 6 patients presented to the rhinology servicewith atelectatic maxillary sinus disease. Each ofthese 6 pediatric patients was treated with bal-loon catheter dilation of the antrum of theaffected sinus. To date, none of the patientshave recurred. Patients who required follow upCT scans have shown complete resolution ofatelectasis. No significant complications havebeen encountered in this cohort to date. Age,gender, race, and complications were recorded.

Results: 6 pediatric patients with silent sinus syndromeunderwent balloon catheter dilation of the maxil-lary antrum without complication.

Conclusions: Balloon catheter dilation of the maxillary antrumcan safely and effectively treat silent sinus syn-drome in the pediatric population. We presentour observations and describe alternative bal-loon dilation technique for successful surgery inthis patient population.

Poster# P-10Clinical practice, professional activities andcareer satisfaction in academic rhinologyAbtin Tabaee, MD, Leon Chen, MD, Timothy LSmith, MD, MPH, Peter H Hwang, MD, RoheenRaithatha, MD, Madeleine R Schaberg, MDNew York, NY USA

Objective: The emergence of rhinology as a distinct sub-specialty has significant implications on residen-cy education and work-force measures. Anunderstanding of the clinical practice, profession-al activities, and career satisfaction in rhinologyare necessary for further definition of the field.

Methods: An anonymous, web-based survey of rhinologyfaculty in otolaryngology residency programswas performed. Respondents were queriedregarding different clinical and professionalactivities and the percentage of their clinicaland surgical practice devoted to various disor-ders. Career satisfaction in multiple domainswas assessed.

Results: 45 respondents successfully completed the sur-vey. A significantly greater degree of time wasdevoted to clinical(40%) and surgical(30%) carewhen compared with research(13%), administra-tive(11%) and teaching(8%) activities. Office vis-its were most commonly devoted to inflammatorysinusitis(47%), rhinitis(19%), nasal obstruc-tion(16%) and skull base pathology(13%).Surgical cases were most commonly devoted toadvanced endoscopic surgery(42%) and routineendoscopic surgery(25%), both for inflammatorysinusitis. Career satisfaction scores were highestfor medical and surgical care, teaching activities,financial and emotional well being and overallcareer to date. Lower satisfaction scores werenoted for research and administrative activitiesand for balance of personal life with work.Female respondents were more likely to devotetime to teaching and reported a higher percent-age of cases devoted to routine endoscopicsinus surgery. Respondents who completedtraining within the past 10 years were more likelyto have completed a fellowship.

Conclusions:The current study further defines the profes-sional, clinical and surgical activities in academ-ic rhinology. An overall high level of career sat-isfaction by rhinologists is described.


Poster# P-11Community-Acquired Methacillin ResistantStaphylococcus aureus Nasal Abscesses ina Lower Socioeconomic Urban PopulationAndrea S Wang, MD, Rita M Roure, MD, Aaron N Pearlman, MDNew York, NY USA

Objective: To determine the prevalence of communityacquired methicillin resistant S. aureus (CA-MRSA) and methicillin sensitive S. aureus(MSSA) nasal abscesses in a lower socioeco-nomic urban population over a five-year period.

Methods: A retrospective chart review of consecutivepatients with nasal abscess cultures performedin the otolaryngology clinic from 2007 to 2012.

Results: 29 cases of nasal abscesses were identified.All cultures grew S. aureus, and 34.5% wereMSSA and 65.5% (90% CI 49.98%-78.32%)were CA-MRSA. Comparing CA-MRSA andMSSA, there was no statistically significantincrease in prevalence of CA-MRSA over fiveyears; and there was no statistical differencecomparing gender, year, or age. There was ahigh rate of erythromycin resistance (15/19) anda low rate of sulfamethoxazole/trimethoprim(2/19) and clindamycin (1/17) resistance in theCA-MRSA cases.

Conclusion: In this population, the proportion of CA-MRSAnasal abscesses is nearly twice that of MSSAnasal abscesses. The overall prevalence ofCA-MRSA appears to be stable over the pastfive years. This may represent a stabilization ofCA-MRSA colonization in this community. Anawareness of the high proportion of CA-MRSAwill allow for the appropriate selection of antibi-otic therapy.

Poster# P-12Comparison of coblation vs. KTP lasercautery treatment for hereditary hemorrhag-ic telangiectasia-related epistaxisNathan B Sautter, MD, Naveen Bhandarkar, MDPortland, OR USA

Introduction: Potassium-titanyl-phosphate (KTP) lasercautery is commonly utilized for treatment ofHHT-related epistaxis (HHT-RE). Coblationcautery has not been rigorously evaluated forHHT-RE.

Methods: Patients seeking treatment for HHT-REbetween September 2010 and September 2011were prospectively randomized to KTP orcoblator cautery. Length of surgery and esti-mated blood loss (EBL) were recorded.Epistaxis severity score (ESS) questionnairesand 10-cm visual analog scales (VAS) for amultitude of HHT-RE symptoms were adminis-tered at enrollment and 3, 6, 12 months follow-ing surgery. Statistical significance was deter-mined using Friedman test and Pearson's Chi-squared analysis.

Results: Thirteen HHT patients were enrolled. 7 patientsunderwent coblation and 6 underwent KTPtreatment. Average age was 64.6, andmale:female ratio was 5:8. One patient in thecoblation group was lost to follow-up. 3patients in the KTP group and 2 patients in thecoblation group requested additional cauterywithin 12 months. There were no complicationsand no significant differences in terms of EBL,surgical time, and length of surgery. Mean ESSwas not significantly different between treat-ment groups at any time point; however, meanESS was higher in the coblator group at base-line and lower at all other time points as com-pared to the KTP group. VAS for nasal obstruc-tion was significantly lower in the coblationgroup at all postoperative time points.

Conclusion: Coblation cautery may be superior to KTPcautery in terms of long-term epistaxis control.Patients experience less nasal obstruction fol-lowing coblation. Further study with greaternumbers is warranted to better determine treat-ment outcomes.


Poster# P-13Dermoid cyst in a patient with frontoeth-moidal sinuses mass: a case reportMohsen Naraghi, MD, Nazanin Hajarolasvadi, MDTehran, Tehran Iran

Introduction: Dermoid cysts are congenital benign anomaliesoriginating from ectodermal tissue during neuraltube closure .these cysts may present in differ-ent region but the incidence of head and neckdermoid cysts is only 7%. Dermoid cyst in fron-toethmoidal sinuses is a rare condition and onlyfew reports noted this type of dermoid cyst.Herein, we report an unusual case of dermoidcyst in frontoethmoidal sinuses presenting asfrontoethmoidal mucocele.

Methods: A 27-year-old man with right medial canthusenlarging mass from 4 years ago had also com-plaint of epiphora with worsening in cold weath-er. The patient does not have any sign of nasalobstruction, postnasal discharge, vision alter-ation or limited eye movements. In CT scan awell-defined mass was noticed in frontoeth-moidal sinuses. Based on clinical and radiologi-cal findings the patient underwent functionalendoscopic sinus surgery.

Results: In surgical procedure, after incising uncinateprocess andentering bulla ethmoidalis, themass with yellow discharge and large amountof hair was revealed. The cyst extending tofrontal sinus was evacuated and removed com-pletely. Pathological evaluation was consistentwith dermoid cyst. Postoperatively, the patient'sepiphora resolved completely.

Conclusion: Mucocele is much more common diagnosis infrontoethmoidal sinuses cystic lesions. Herein,we presented a case of dermoid cyst as a pos-sible diagnosis of masses in this region andshould be considered in differential diagnosis ofpatients with frontoethmoidal mucoceles.

Poster# P-14Diagnostic Characteristics of SinonasalOrganizing Hematomas: AvoidingMisdiagnosisArthur W Wu, MD, Jonathan Y Ting, MD, PeterM Sadow, MD, PhD, Amy F Juliano, MD, StacyT Gray, MD, Eric H Holbrook, MDBoston, MA USA

Introduction: Organizing hematomas of the paranasal sinus-es can be a diagnostic dilemma. Based onclinical presentation, endoscopic examinationand radiographic analysis, these lesions can bemisinterpreted as an aggressive malignantprocess. Establishing diagnostic criteria foridentifying these lesions pre-operatively wouldfacilitate appropriate management and patientcounseling.

Methods: Retrospective case series of seven patientswith sinonasal organizing hematoma.Radiographic imaging, pathology, and clinicalpresentations were reviewed for identifyingcharacteristics common among each case.

Results: The most common presenting symptomsincluded epistaxis, nasal obstruction and facialpressure. Four patients had masses visible onnasal endoscopy. Pre-operative biopsy ofthese masses were consistently non-diagnostic.Radiographically, the most diagnostic findingwas "shells" of T2 hypointensity on MRI sur-rounding a central lobulated mass. Theseshells correspond to rims of fibrosis at theperiphery of the mass on pathology, and areasof fresh hemorrhage are found at the center ofthese lobules.

Conclusion: Sinonasal organizing hematomas are rarelesions of the sinonasal cavity whose clinicalcharacteristics are often pre-operatively sug-gestive of a benign or malignant neoplasm.Endoscopy, preoperative biopsy, and CT imag-ing do not lend helpful information in differenti-ating these lesions from a neoplastic process.However, MR imaging can lead to positive diag-nosis by recognizing the distinct outer rims ofT2 hypointensity typically seen in these lesions.


Poster# P-15Endoscopic Graduated Multi-AngleResection of Juvenile NasopharyngealAngiofibroma: Minimizing Facial Incisions-Technical Note and Report of 4 CasesMohemmed N Khan, BA, QasimHusain, BS,James K Liu, MD, Jean Anderson Eloy, MDNewark, NJ USA

Introduction:The infratemporal fossa (ITF) has been one ofthe more difficult areas of the skull base toaccess. Traditional open procedures do notalways afford optimal visualization, leading tosignificant morbidity and poor cosmesis.Juvenile nasopharyngeal angiofibroma (JNA) isa highly vascular, benign neoplasm that,despite slow growth, has the potential for localinvasion and requires resection. The advent ofendoscopic procedures has allowed for resec-tion of JNA from the ITF with greater surgicalfreedom and decreased incidence of facialdeformity and scarring.

Methods: This case series presents four cases of resec-tion of JNA (each with a different surgical com-plexity) with emphasis on minimizing facial inci-sions through multi-angle endoscopic tech-niques. The use of three different endoscopicapproaches to the ITF in varying combinationsis described. Demographic data, history, loca-tion of lesion, and procedure specifics are dis-cussed.

Results: A graduated multiangle endoscopic approachusing a combination of an ipsilateral nasalapproach, a contralateral transseptal approach,and a submaxillary approach were used toallow for superior surgical maneuverability forresection of JNA from the ITF in all fourpatients. Decisions on optimal combination ofapproaches were made based on the size andexact location of the tumor. All four patients hadsuccessful outcomes without facial incisions.

Conclusions: Access to the ITF can be gained through appro-priate combination of the three endoscopic pro-cedures described. Using a multiangleapproach to this area allows for greater surgicalcustomization of access to JNA resectiondepending on the size and exact location of thetumor.

Poster# P-16Endoscopic posterior nasal neurectomy: thestate of the artTakeo Kanaya, MD, Kenji Kawano, MD, Toru Kikawada, MDChuo-ku, Tokyo Japan

Objective: Endoscopic posterior nasal neurectomy (EPNN)was first reported in 1997. Since then, our clin-ics have performed EPNN on more than 4500patients suffering from allergic and nonallergicrhinitis. We have refined the technique continu-ously, and this paper presents our most currenttechnique.

Methods: EPNN is performed under general anesthesia.We make two incisions, one at the middle mea-tus and the other incision at the inferior meatus.A suction-irrigation system allows us to resectthe lateral posterior superior nasal nerves(LPSNN) and the posterior inferior nasal nerves(PINN) while preserving the blood vessels.EPNN is not combined with other proceduressuch as inferior turbinoplasty.

Results: We compared the pre-operative and post-opera-tive area of the nasal cavity by CT scans onemonth after surgery. We confirmed a reductionin hypertrophy of the mucosa of the inferiorturbinates, middle turbinates, and nasal septum.

Conclusions: Current EPNN reduces nasal obstruction effec-tively by expanding the nasal pathways aroundthe middle and inferior turbinates. Severe com-plications are avoided because direct vision,provided by the suction-irrigation system, allowsdifferentiation of nerves from blood vessels.


Poster# P-17Endoscopic Removal of Massive Sinonasaland Skull Base Cavernous HemangiomaOlga Kovalerchik, BA, Qasim Husain, BS,Saurin Sangvhi, BS, Zain Boghani, BS, JamesK Liu, MD, Jean Anderson Eloy, MD, FACSNewark, NJ USA

Introduction: Hemangiomas of the nasal septum andparanasal sinus, although rare, must be consid-ered in the evaluation of an intra-nasal masswith large volume epistaxis. While the availabili-ty of literature discussing cavernous heman-giomas of the nose is limited, there has notbeen a case reported of an exclusively soft-tis-sue sinonasal cavernous hemangioma thatextends to the skull base. Here we describe thesuccessful endoscopic resection of a massiveright sinonasal cavernous hemangioma thatextends to, but does not involve, the anteriorskull base.

Methods: Case report and current literature review.

Results: A 66 year-old man who was referred to our hos-pital with profuse epistaxis and a large right-sided nasal mass. CT and MRI scanningdemonstrated a vascular mass in the anteriorskull base with severe ipsilateral septal devia-tion as well as disease in the right frontal andmaxillary sinuses. Histological examinationrevealed a cavernous hemangioma. A success-ful resection of this right sinonasal/anterior cra-nial fossa extradural mass was achieved usingan endoscopic endonasal approach.Septoplasty, right frontal sinusotomy, and rightmaxillary antrostomy were also performed onthis patient using sinonasal endoscopy. Thepatient tolerated the procedure well and hasshown no signs of bleeding or complications inthe months after the operation.

Conclusion: An uncommon tumor of the nasal cavity andparanasal sinuses has been found in anextremely rare site. The aim of this report is toincrease awareness of sinonasal cavernoushemangiomas and to reinforce the use of endo-scopic approach for efficient treatment ofpatients with this condition.

Poster# P-18Endoscopic Skull Base Surgery PracticePatterns:Survey of the North American SkullBase Society (NASBS)Pete S. Batra, MD, FACS, Jivianne Lee, MD,Samuel L. Barnett, MD, Brent A. Senior, MD,FACS, Michael Stezen, MD, FACS, Dennis H.Kraus, MDDallas, TX USA

Introduction: The objective of this study was to evaluate thepotential impact of advanced endoscopic tech-niques on the current practice patterns in skullbase surgery.

Methods: A 21-item written survey approved by the ARSand NASBS was conducted at the 22nd AnnualNASBS meeting in Las Vegas, NV, fromFebruary 17-19, 2012. The target group includ-ed 212 practicing skull base surgeons.

Results: Seventy-nine physicians (37.3%) completed thesurvey. The subspecialty composition included 42(53%) otolaryngologists and 35 (44%) neurosur-geons. The respondents represented all regionsof the country, with most common being northcentral (24%) and mid-Atlantic (23%) states.Open and endoscopic skull base techniqueswere used by 91% and 80%, respectively. Duringa typical year, the number of endoscopic skullbase cases ranged between 20-50 in 32%, 50-100 in 13%, and >100 in 8%. Endoscopic pitu-itary surgery was performed by 95%, while tran-scribriform, transplanum, and transclivalapproaches were utilized by 70.5%, 66%, and66%, respectively. Wide variation in coding phi-losophy was noted, including use of unlisted neu-rosurgical (34%), open skull base (24%), unlistedendoscopic (20%), and sinus surgery (20%)codes. Only 30% of physicians reported ade-quate reimbursement in =50% of the performedcases. Overall, 87% were supportive of creationof dedicated endoscopic skull base codes.

Conclusions: The present survey attests to the widespreadadaptation of endoscopic techniques in themanagement schema of skull base surgery.The wide variation in coding techniques andinadequate reimbursement suggests that futuredialogue should also focus to develop consen-sus of the billing and coding process.


Poster# P-19Evaluation of intravenous tranexamic Acidon Bleeding during Functional EndoscopicSinus SurgeryFatemeh Hajimohammadi, MD, MohsenNaraghi, MD, Afshar Etemadi Aleagha, MD,Mehrdad Behzadi, MD, Payman Dabirmoghaddam, MDTehran, Tehran Iran

Introduction: Bleeding during functional endoscopic sinussurgery (FESS) remains a challenge for bothsurgeons and anesthesiologists despite severalmodalities available for improving the surgicalfield. In spite of demonstrated favorable effectsof trancexamic acid (TA) on bleeding tendencyin cardiac, major or thopedic, transplantationand prostate surgeries, It's intravenous (IV) usein FESS has never been examined. This studywas conducted to evaluate the efficacy of intra-venous TA in improving the surgical field inFESS.

Materials and Methods:In placebo-controlled clinical trial a total of 88ASA physical status I-II patients, aged 15-66years, undergoing endoscopic sinus surgeryunder general anesthesia were allocated basedrandomly table number, to receive either intra-venous TA 15mg/Kg or sterile water 200cc as abolus dose immediately before induction ofanesthesia. Anesthesia and surgery protocolswere the same in both groups. Bleeding andsatisfaction scores were obtained from the sur-geon and his aid and compared between twogroups.

Results:In view of the surgeon, the median (range)bleeding scores in the TA group was 98.41(51.35) and in placebo group was 148.98(71.75) (P value=0.01). Accordingly the surgeonwas more satisfied with the surgical field in theTA group than placebo group.

Conclusion: Based on various parameters, intravenous TAcannot clinically reduce bleeding during FESS.

Poster# P-20Geometric Alopecia Following PreoperativeAngioembolization of JuvenileNasopharyngeal AngiofibromaAlejandro Vazquez, MD, Pratik A Shukla, MD,Osamah J Choudhry, MD, Chirag D Gandhi,MD, James K Liu, MD, Jean Anderson Eloy,MD, FACSNewark, NJ USA

Background: Preoperative angiography and subsequentembolization of the vascular supply of JuvenileNasopharyngeal Angiofibroma are routinely per-formed for larger tumors to decrease intraoper-ative bleeding. Geometric alopecia fromangioembolization of JNA has not been previ-ously reported in the otolaryngologic literature.In this case report, we discuss geometric alope-cia from radiation exposure during preoperativeangioembolization of a JNA.

Methods: Case report.

Results: A 13-year-old male with a three-monthhistory of nasal obstruction was referred to ourinstitution for evaluation and management of aright sinonasal mass after a biopsy was consis-tent with JNA. CT and MRI demonstrated alarge, primarily right-sided nasopharyngeallesion with extension into the right pterygopala-tine fossa, infratemporal fossa, bilateral sphe-noid sinuses, as well as erosion of the anteriorclivus and right pterygoid plates. Nasal endo-scopic evaluation revealed a large massobstructing the right nasopharynx with deviationof the posterior nasal septum to the left. The leftInternal maxillary artery was subsequentlyembolized with N-Butyl Cyanoacrylate (NBCA)glue. The patient underwent uneventful endo-scopic resection of the tumor. At six-week fol-low-up, the patient was noted to have a large,well-demarcated, semicircular segment ofalopecia in the right occipitoparietal region.

Conclusion: Preoperative JNA embolization for gross totaltumor resection may result in radiation expo-sure related consequences. Although alopeciamay be a relatively benign complication of thefluoroscopic guided procedures, changes inexternal appearance may have a psycho-socialeffect on patients and may be permanent.Otolaryngologists must be aware of this entityin order to adequately educate and inform theirpatients.


Poster# P-21Hemangiopericytoma in paranasal sinuses:A Ten Years StudyMohsen Naraghi, MD, Farveh Ramezanzadeh,MD, Saeed Shoar, MD, Massoud Boroojerdi,MD, AmirHoushang Omidvari, MD, SaraEsmae ili, MD, Sorro Kalantari, MDTehran, Tehran Iran

Introduction: Hemangiopericytoma is a very rare vasculartumor with one of the least prevalences report-ed in paranasal sinuses. We reported elevencases of hemangiopericytoma who werereferred to our center in the past ten years toprovide evidences about clinical features of thistumor and its treatment outcomes.

Methods: We retrospectively reviewed the hospital database to extract the medical records of diag-nosed hemangiopericytoma cases in the past10 years.

Results: Of eleven cases included in our study, 3 (27%)patients were male compared to 8 female(73%) with an average age of 40 years. Ten ofthe patients (91%) were referred from urbanhealth center. The presenting symptoms include6 nasal obstruction, 4 nasal mass, 2 epistaxis,1 exophthalmia, 1 nasal congestion, 1 nasalpain, and 1 ocular mass. Sinus involvementshad been observed in maxillary sinus of 7patients, ethmoid sinus of 5 patients, and sphe-noid sinus of 1 case. 7 (64%) tumors wereremoved by endoscopic surgery, preoperativeembolization was performed in 6 of them. Theremainder 4 (36%) had been treated with opensurgical approaches.

Conclusion: In contrast to the literature, our records showedthe maxillary as the most common site ofhemangiopericytoma followed by ethmoid andthe least common sphenoid. It may be due tothe secondary involvement of the maxillarysinus. Endoscopic surgery with preoperativeembolization could be an acceptable method forresection of tumor.

Poster# P-22Hyaluronic Acid and External Nasal ValveFunction: A New Alternative for SurgeryMohsen Naraghi, MD, Alain Fabrice Sontou, MDTehran, Tehran Iran

Introduction: Improvement of external nasal valve function isone of the most challenging issues in nasal sur-gery. Despite complicated techniques based onutilizing different grafts and sutures, long termresults are still under debate. There areincreasing indications for generous use ofhyaluronic acid in otorhinolaryngology includinglaryngology and facial plastic surgery with onlyfew articles on its use in rhinology and internalnasal valve. This is the first experience onhyaluronic acid improvement of the externalnasal valve.

Method:In this study, we present our experience on 32patients with the complaint of nasal obstructiondue to collapse of the external valve, with orwithout internal valve problem. The epicenter ofobstruction and severity was determined byphysical examination, nasal endoscopy, rhino-manometry and acoustic rhinometry. All patientsunderwent augmentation of the weakenedareas of the external nasal valve with hyaluron-ic acid injection.

Results:Comparison of pre and post-procedure symp-tom groups was performed in all patients andrevealed that functional problem improved in allof the patients, with a wide range of changesfrom minor to major improvement. The immedi-ate result experience was exciting for manypatients.

Conclusion:Hyaluronic acid nasal valve procedures couldbe an easy, safe and cost effective method forimproving external nasal valve function in pri-mary and revision cases. However it should bedone very cautiously by an expert surgeon withample experiences on surgical correction of theexternal nasal valve to make this alternativetechnique in selected patients, mimicking therole of the supporting grafts.


Poster# P-23Hyperostotic Esthesioneuroblastoma: CaseReport and Review of the LiteratureMurugappan Ramanathan, MD, Anand V. Germanwala, MDBaltimore, MD USA

Introduction: Esthesioneuroblastoma is an uncommon malig-nant neoplasm that arises from the olfactoryneuroepithelium and is largely considered a softtissue tumor. We report a rare case of esthe-sioneuroblastoma with extensive hyperostosisof the tumor, skull base, and lamina papyracea.

Methods: Case report and review of the literature.

Results: A 42 year old male presented to clinic with a leftabducens palsy and diplopia. Imaging by CTscan and MRI revealed a large left sided skullbase tumor with intracranial invasion in the set-ting of extensive osteoblastosis of the middleturbinate, skull base, and left lamina papyracea.Endoscopic biopsy of this lesion revealedesthesioneuroblastoma. The patient underwentan endoscopic-assisted bifrontal craniotomy forexcision of this tumor in addition to a left sidedorbital decompression to remove the hyperos-totic lamina papyracea. The large skull basedefect was reconstructed using both a pericra-nial flap and a vascularized pedicled nasoseptalflap. Postoperatively, the patient had a resolu-tion of his abducens palsy. As the extensivehyperostotic skull base could not be entirelyresected, the patient underwent chemotherapyand radiation therapy.

Conclusions: A survey of the literature reveals one priorreport of 2 cases without as extensive anosteoblastic reaction as this case. In conclu-sion, the presence of an osteoblastic reaction inthe setting of a soft tissue mass in the nasaland intracranial cavities is rare and esthe-sioneuroblastoma should be considered in thedifferential diagnosis. Management shouldinclude a multidisciplinary approach towardssurgical resection and postoperativechemotherapy and radiation if indicated.

Poster# P-24Idiopathic Sclerosing InflammationPresenting as SinusitisHenry P Barham, MDAurora, Colorado USA

Background:Idiopathic sclerosing orbital inflammation is arare finding that is poorly delineated, immunemediated and causes severe symptoms anddisability. It has been described affecting theorbit in addition to other sites within the headand neck, but has rarely been described pre-senting as sinusitis.

Methods: Case Report and literature review.

Results: A 14-year-old female with right sided face andeye pain and pressure for greater than 1 monthpresented 3 days after endoscopic sinus sur-gery for presumed acute sinusitis. She subse-quently developed ipsilateral vision loss andhypesthesia of the infraorbital nerve. MRIrevealed a mildly enhancing soft tissue intensitylesion extending from the right maxillary sinusinto the pterygopalatine fossa and orbital apexthrough the inferior orbital fissure. Biopsies ofthe lesion were consistent with a sclerosinginflammatory lesion. High dose steroids lead torapid improvement in vision and pain, howeverthe patient was unable to tolerate steroid wean-ing due to recurrence of eye pain andheadache. Repeat imaging demonstrated pro-gression of the lesion. Rheumatology was con-sulted and the patient's steroid therapy wasaltered and her medications expanded toinclude azathioprine. The patient's symptomsimproved and subsequent imaging demonstrat-ed a reduction in the size and extent of thelesion.

Conclusion:Idiopathic sclerosing inflammation is character-ized by primary, chronic, and immunologicallymediated fibrosis. Patients typically have a poorresponse to corticosteroid treatment or radio-therapy. Immunosuppressive therapy in additionto Corticosteroids is the recommended treat-ment.


Poster# P-25In-Office Balloon Dilation and Drainage ofFrontal Sinus MucoceleJean Anderson Eloy, MD, FACS, Qasim Husain, BS, Pratik A Shukla, MD,Osamah Choudhry, MD, Jean Daniel Eloy, MD,Paul D Langer, MD, FACSNewark, NJ USA

Introduction: Treatment of frontal sinus disease representsone of the most challenging aspects of endo-scopic sinus surgery. Frontal sinus mucoceledrainage may be an exception to the rule, sincein many instances; the expansion of the muco-cele widens the frontal sinus recess and ren-ders surgical drainage technically undemand-ing. The past few years have witnessed andincreased use of balloon dilation devices insinus surgery. In this report, we describe ourstep-by-step in-office experience using this toolfor drainage of a large frontal sinus mucocele.

Methods: Case report

Results: A 68-year-old woman presented with a 2-yearhistory of asymptomatic progressive right eyeproptosis and pressure. Nasal endoscopicexamination revealed a deviated nasal septumto the left side and a widened right middle mea-tus and frontal sinus recess. CT of the orbitsand paranasal sinuses showed a right frontalsinus expansile lesion and MRI showed a largeright frontal sinus mass with signal intensityconsistent with a frontal sinus mucocele. Afteran adequate anesthesia effect, the mucocelecontent was partially drained with a 21-gaugeneedle. The frontal sinus recess area was sub-sequently cannulated using the transnasal bal-loon dilation probe (Entellus Medical Inc., MapleGrove, MN) under direct endoscopic visualiza-tion with a 30 or 70-degree endoscope.Postoperatively, the patient's proptosis was sig-nificantly decreased and CT showed a widelypatent right frontal sinus cavity.

Conclusion:In-office frontal sinus mucocele drainage usingballoon dilation appears to be a feasible tech-nique and potential alternative to conventionalendoscopic procedures in the operating room.

Poster# P-26In-Office Jones Tube Exchange Using theSeldinger TechniqueJean Anderson Eloy, MD, FACS, SaurinSangvhi, BS, Osamah J. Choudhry, MD, PratikA Shukla, MD, Jean Daniel Eloy, MD, Paul DLanger, MD, FACSNewark, NJ USA

Introduction: Conjunctivodacryocystorhinostomy (CDCR) withJones tube placement is usually performed as aprimary procedure for severe stenosis orobstruction of both upper and lower canaliculi ofthe lacrimal drainage pathway, or occasionally,after unsuccessful dacryocystorhinostomy(DCR). Jones tube obstruction is quite com-mon, and often requires removal of theobstructed tube and replacement or exchangeof the tube in the operating room. In this report,we describe a novel in-office method toexchange an obstructed Jones tube that pro-vides the aforementioned benefits while pre-serving patient comfort.

Methods: Case report.

Results: A 66-year-old woman with a history of multipleprocedures (including Jones tube placement)for treatment of lacrimal duct obstruction pre-sented with left-sided tearing. Rigid 30-degreenasal endoscopic examination revealed a devi-ated nasal septum superiorly to the right sidewith an obstructed Jones tube lumen secondaryto thick crusting. An in-office exchange of theJones tube using the Seldinger technique wasperformed. Patient is currently doing well 2years after the procedure and only requiresperiodic Jones tube care.

Conclusion:In-office Jones tube exchange using theSeldinger technique is feasible and representsa potential alternative to conventional tubeexchange performed in the operating room. Incarefully selected patients, this technique maynegate the need for general anesthesia anduse of the operating room, reducing surgicaltime and cost.


Poster# P-27In-Office Vasovagal Response AfterRhinologic ManipulationQasim Husain, BS, Brian M Radvansky, BA,Saurin Sangvhi, BS, Osamah J Choudhry, MD,Jean Anderson Eloy, MD, FACSNewark, NJ USA

Introduction: Over the past decade, multiple improvementshave been made in instrumentation and surgi-cal techniques for endoscopic sinus surgery(ESS). These improvements have caused ashift towards more minimally invasive proce-dures and from the operating room towards in-office procedures. With the increased numberof in-office procedures, one can expect anincrease in the number of potential complica-tions. The incidence of vasovagal episode inthe office during rhinologic procedures has notbeen previously reported. In this study, we dis-cuss our experience with patients who suffereda vasovagal response during in-office rhinologicmanipulation.

Methods: A retrospective analysis at a large tertiary refer-ral center was performed on all patients under-going in-office rhinologic manipulation betweenJuly 2008 and June 2012. During this period, atotal of 4973 patients underwent proceduresinvolving endoscopic diagnosis or treatment.

Results: Eight patients (0.16%) out of 4973 experiencedvasovagal syncope during in-office endoscopicmanipulation. Seven of eight patients recov-ered from the vasovagal episode and were dis-charged home after 30 minutes of observation.One of the eight patients did not fully recoverwithin 60 minutes and was sent to theEmergency Department, where the patient wasstabilized and discharged the same day.

Conclusion: While the incidence of vasovagal syncope dur-ing rhinologic manipulation remains low, it haspotentially deleterious effects that rhinologistsshould be prepared to manage.

Poster# P-28Intraoperative Grading of Maxillary SinusDisease: Reliability, Validity, and ClinicalApplicationMarc A Tewfik, MD, MSc, FRCSC, LeighSowerby, MD, FRCSC, Andrew Foreman,BMBS, PhD, Stephen Floreani, MD, FRACS,Peter-John Wormaild, MD, FRCS, FRACSMontreal, QC Canada

Introduction: Effective management of the maxillary sinus iskey to the success of endoscopic sinus surgery.However, depending on the severity of disease,different approaches are required to achievethis. In order to aid intraoperative decision-mak-ing, a grading system for maxillary sinus dis-ease has been created, ranging from 1 to 3based on the appearance of the mucosa andmucus content of the sinus. The purpose of thisstudy is to assess the intra-rater, inter-rater andtest-retest validity of this system.

Methods:Four blinded otolaryngologists were recruitedand presented with a short instructional video,followed by 100 randomly ordered clips of max-illary antrostomies performed by the seniorauthor for chronic sinusitis. Scores from seniorauthor were used as the gold standard. A sec-ond viewing of the videos in a different orderwas scored two weeks later to examine thetest-retest reliability. Statistical analysis wasperformed using ordered logistic regressionmodels.

Results: Average inter-rater agreement was 70.5%(kappa = 0.66), intra-rater agreement was 94%(kappa = 0.88), and test-retest agreement was88% (kappa = 0.79). The scores assigned bythe senior author were used to select the surgi-cal approach used to address each sinus.

Conclusion: Our study confirm the intra-rater and test-retestvalidity of the maxillary grading system, andsuggest an acceptable inter-rater validity. Theclinical utility of this system is in guiding intraop-erative decision-making for the maxillary sinusbetween uncinectomy alone, antrostomyenlargement, and trephination. Representativecase examples and outcomes will also be pre-sented.


Poster# P-29Invasive Fungal Sinusitis with DisseminatedCutaneous Disease Treated Successfullywith Aggressive Surgical and MedicalTherapyMichael D Lupa, MD, Zara M Patel, MDAtlanta, GA USA

Background: Surgical debridement and medical therapy withantifungal agents are the standard of care forthe treatment of acute invasive fungal sinusitis(IFS). What is debated is the degree of surgeryto perform, and for which patients surgery pro-vides a survival benefit. We present twopatients that had disseminated fungal infectionwith cutaneous manifestations who underwentendoscopic debridement of their sinonasal dis-ease and medical therapy, who achieved con-trol of their infections.

Methods: Case series

Results: Patient one was a 66 year old male with AMLwith persistent neutropenia. He developedpainful erythematous skin nodules which onbiopsy revealed fungal organisms with angioin-vasion. IFS with Fusarium species was subse-quently diagnosed during workup for a sourceof disseminated infection. The patient under-went endoscopic debridement with concurrentmedical therapy. He was discharged home fourweeks later with no further progression of hisfungal infection. Patient two was a 24 year oldfemale with relapsed ALL and persistent neu-tropenia. The patient developed painful nod-ules on her extremities which on biopsyrevealed Fusarium. On workup for a source ofinfection, IFS was discovered. She underwentendoscopic debridement with medical therapy.The patient was subsequently discharged homewith no further fungal disease progression.

Conclusions: We present two patients with disseminatedfungemia with cutaneous manifestations andIFS that survived their infections with aggres-sive surgical debridement and medical therapy.Some authors have questioned the value ofsurgical intervention in this group of patients butin these two individuals, control of the fungalinfection was achieved.

Poster# P-30Management of Sinonasal Chondrosarcoma:A Systematic Review of 158 PatientsMohemmed N Khan, BA, Qasim Husain, BS,Zain Bhogani, BS, Jean Anderson Eloy, MD,FACSNewark, NJ USA

Introduction:This study reviews the published outcomesrelated to management of sinonasal chon-drosarcoma. Clinical presentation, demograph-ics, imaging characteristics, treatment, andmanagement outcomes of this uncommon dis-ease are reported.

Methods: A systematic review of studies for sinonasalchondrosarcoma from 1950 to 2012 was con-ducted. A PubMed search for articles related tothis condition, along with bibliographies of theselected articles was performed. Articles wereexamined for individual patient data (IPD) thatreported survivability. Demographic data, dis-ease site, treatment strategies, follow-up, out-come, and survival were analyzed.

Results: A total of 63 journal articles were included,comprising a total of 158 cases of sinonasalchondrosarcoma. The average follow-up was77 months (range, 1 to 325.2 months). Surgicalresection was the most common treatmentmodality with a 5-year survival of 74.4%. Acombination of surgery and radiation therapywas the second most commonly used treatmentmodality with a 5-year survival of 83.2%. Theoverall 5-year survival rate for all treatmentmodality was 76.5 %.

Conclusions: This review contains the largest pool ofsinonasal chondrosarcoma patients to date andprovides support for the use of aggressive sur-gical resection in this condition. The use ofadjunctive radiotherapy for prevention of localrecurrence after subtotal or total resection didnot show significant improvement. However, theuse of adjuvant radiotherapy trended toward ahigher 5-year survival.


Poster# P-31Management of SinonasalHemangiopericytomas: A Systematic ReviewMufaddal Q Dahodwala, MS, Qasim Husain,BS, Saurin Sangvhi, BS, Osamah J Choudhry,MD, James K Liu, MD, Jean Anderson Eloy,MD, FACSNewark, NJ USA

Introduction: Hemangiopericytomas are typically found insoft-tissue, but only rarely found in thesinonasal tract. Cases of these sinonasalhemangiopericytomas have been reportedmostly through case studies, and optimal treat-ment is considered surgical excision. With thewider use of endoscopic methods, an updatedsystematic review of the treatment of thesecases is warranted.

Methods: Cases were identified using a broad MEDLINEand PubMED search. Relevant studies wereidentified, and data was extracted regardingpatient demographics, presenting symptoms,tumor characteristics, treatment, and outcomes.

Results: One hundred and twenty-eight cases were col-lected from 56 articles, consisting of casereports and series. The most common present-ing symptoms were epistaxis, nasal obstruction,and facial pain/swelling/pressure. Computedtomography and X-ray were the most commonmodes of imaging during diagnosis and opera-tive planning. In most cases, the tumor occu-pied more than one distinct location in thesinonasal tract at initial presentation. Surgicalresection was the mainstay of treatment in 125of the 128 cases (97.7%), either through openresection or endoscopic techniques. Surgicalremoval resulted in no recurrence in 78.9% ofthe cases. The use of endoscopic techniquesincreased significantly in the past decade.

Conclusion: Surgical management remains the mainstay oftreatment for hemangiopericytomas.Endoscopic resection of these lesions has sig-nificantly increased over the last decades andhas become a safe, viable, and preferred alter-native to open resection in selected patients.

Poster# P-32Management of Sinonasal Neoplasms byEndoscopic and Combined ApproachesMohsen Naraghi, MDTehran, Tehran Iran

Introduction: Recent advances in treatment of nasal andparanasal sinus tumors have evolved to theminimally invasive endoscopic surgery as theexclusive management for most cases ofbenign tumors and as a combination method inmost cases of malignant tumors. In this paper,16 years of personal experience in endonasalendoscopic surgery for sinonasal neoplasmswill be discussed, emphasizing advantages,disadvantages and recent advances in thisfield.

Methods: Since 1997 more than four hundred fifty fourcases of sinonasal neoplasms underwent endo-scopic surgery as the exclusive surgical inter-vention or a combination procedure. In endo-scopic hybrid group, the endoscope entered lib-erally through the open accesses to give themaximum view and reduce recurrences.Angiofibroma was the most common pathologyamong the tumors with one hundred thirty twocases, of which one hundred twelve of themwere performed exclusively endoscopically.

Results:Surgical plan was established on the basis ofpathologic condition and location of tumor. Mostof benign lesions were managed by endoscopicsurgery with lower recurrence rate. In extensiveintracranial extensions or in some malignantlesions, combinations with an externalapproach were valuable. Postoperativeendoscopy was performed regularly for detec-tion of recurrence.

Conclusion: Endoscopic surgical resection could enhancecomplete tumor removal by providing excellentmagnified and angled view, with or withoutcomplementary approaches. It could be accom-plished not only by endonasal routes, but alsoas combination with open approached toenhance the accuracy and vision. Image guidedsurgery could help to make a safe surgery withmore confidence in tumor removal.


Poster# P-33Nasal Septal MucopyoceleSenja Tomovic, MD, Chirag R Patel, MD, KiHan, MDNewark, NJ USA

Introduction:Mucoceles are expansile mucous collectingcysts which may develop secondary to iatro-genic injury, chronic infection, allergic sinonasaldisease, or trauma. They occur most common-ly in the paranasal sinuses and may becomeinfected, at which point they are referred to asmucopyoceles. Worldwide, only 4 cases ofnasal septal mucoceles and only one case of anasal septal mucopyocele have been describedin the literature. We present the case of anasal septal mucopyocele encountered at ourinstitution.

Method: Case Report

Results:A 60 year old male who underwent septoplasty20 years prior presented with complaints of pro-gressively worsening bilateral nasal obstructionover many years as well as bilateral middle eareffusions and conductive hearing loss. Imagingdemonstrated a cystic lesion of the nasal sep-tum which was found intraoperatively to containmucopus. Mucopyocele was confirmedhistopathologically. This is only the secondreported case of a nasal septal mucopyocele.

Conclusion:While exceedingly rare, mucocele and mucopy-ocele may occur in the nasal septum andshould be considered in the differential of anasal cavity mass. This should also be kept inmind as possible complications of surgeryinvolving the nasal septum.

Poster# P-34Nasopharyngeal Chordoma; a Case Report.Hakan Cincik, MD, Dogan Pinar, MD, EvrenErkul, MD, Atila Gungor, MDIstanbul, NA Turkey

Subject: Chordomas orginating from embryonic remnantof the nothocord are rare, slowly enlarging,local aggressive, benign tumor of the skull baseand sacrum. Chordoma typically arises fromclivus and enlarges to the around structures ofskull base and destructs them. If chordomaoccurs in nasopharynx, it can mix-up with othertumors of the nasopharynx.

Case report: 56 years female presented with headache asthe sole complaint, who was treated by neurolo-gy clinic as a diagnosis of tension typeheadache for a year. MRI showed a massplaced middle of the nasopharynx and involvedthe nasal septum. Endoscopic examinationshowed a mass with a smooth mucosal sur-face. She underwent a nasal endoscopic sur-gery for a biopsy and frozen pathologic assess-ment reported as a chordoma. Surgical teamdecided to the total resection of the mass.Permanent histopathologic result was same asthe frozen report. She sent for RT.

Conclusion: When chordoma occure in nasopharynx it maymimic other tumors. MRI and CT are veryimportant tool differentiating chordoma from theother mass. If chordoma is diagnosed innasopharynx, Transnasal Endoscopic approachis good way to remove it.


Poster# P-35Ophthalmic artery aneurysm presenting asspontaneous high volume epistaxisKara Y Detwiller, MD, Peter E Andersen, MD,Nathan B Sautter, MDPortland, Oregon USA

Introduction: High volume epistaxis secondary to aberrationsof the internal carotid artery (ICA) circulation israre and potentially life-threatening. We pres-ent a case report of a patient with an oph-thalmic artery aneurysm who developed highvolume epistaxis.

Methods: Chart review.

Results: The patient presented initially in March 2001with persistent sphenoid sinus CSF rhinorrheafollowing failed aneurysm clipping via pterionalcraniotomy approach. Endoscopic repair of theCSF leak was unsuccessful, and the patientultimately required revision craniotomy withreconstruction of the skull base using a vascu-larized free flap. The patient recovereduneventfully, but presented in December 2011with several episodes of spontaneous, left-sided, high volume epistaxis while working athigh altitude, requiring blood transfusion.Angiography of the ICA revealed a persistentaneurysm with a small area of extravasationand embolization coils outside of the lumen ofthe aneurysm; however, this was not felt at thetime to be the source of his bleeding and there-fore embolization of the left facial and maxillaryarteries was performed. The patient returnedtwo weeks later following another episode ofhigh volume epistaxis, and endoscopic exami-nation under anesthesia revealed visible plat-inum coils present in the posterior left sphenoid.The patient subsequently underwent endovas-cular pipeline shunt embolization of the residualaneurysm resulting in resolution of epistaxis.

Conclusion: We present an unusual case of potentially life-threatening high volume epistaxis that mayhave been unmasked by low barometric pres-sure at high altitude. The ophthalmic arteryaneurysm responsible for the epistaxis wassuccessfully treated with a pipeline emboliza-tion device.

Poster# P-36Orbit Surgery by the Nose: The State of ArtMohsen Naraghi, MDTehran, Tehran Iran

Introduction: The origin of orbital lesions could be intraorbital,sinonasal or intracranial. Various surgicalapproaches have been applied for treatment ofthe orbital pathologies. The medial orbital wallis composed mainly of lamina papyracea whichcould be accessed easily through the ehtmoidsinuses. In this article, personal experiences inendoscopic approach to the orbital lesions havebeen explained.

Materials & Methods: Three hundred thirty patients with differentorbital lesions underwent endoscopic orbitalsurgery in fifteen years period. A standard ante-rior and posterior ethmoidectomy were per-formed in most of cases. In sinogenic orbitallesions, treatment was complete by treatingsinus of origin. In the case of the intact laminaparyracea, it was removed followed by an inci-sion through the periosteum. At the latter stage,much percision was applied to avoid bleedingand occular muscles injury.

Results: The outcomes were dependent on the type ofthe lesions. In the inflammatory conditions, theendoscopic surgery was performed as a cura-tive modality with functional benefits for thesinuses. In the benign lesions, complete resec-tion of the tumor was accomplished exclusivelyendoscopic in most of the cases. Malignanttumors such as intraorbital lymphoma frequent-ly required other therapeutic modalities.

Conclusion: Endoscopic surgery could be an alternativetreatment for a wide variety of orbital lesionsincluding orbital masses. The endonasal routeshave the advantages of being less invasive,excellent homeostasis, time saving and noscars compared to the traditional externalapproaches. Disadvantages include a steeperlearning curve, higher equipment cost and needfor an experienced surgeon.


Poster# P-37Outcomes of the Transpterygoid Approachto Lateral Sphenoid Sinus CSF Leaks andMeningoencephalocelesNadieska Caballero, MD, Kevin C Welch, MDMaywood, IL UStA

Background: Data regarding the management of meningoen-cephaloceles and cerebrospinal fluid (CSF)leaks in the lateral recess of the sphenoid sinus(LRS) are sparse. In this study, we describeendoscopic repair of these lesions via atranspterygoid (TPTG) approach and reportassociated complications.

Methods: A retrospective review of patients who under-went endoscopic TPTG repair from 2007-2011was conducted. Data collected included demo-graphics, BMI, defect size, sinus pathology, andplacement of a lumbar drain. Complicationsincluding V2 numbness, ocular dryness, cere-brovascular events, headaches, bleeding, rhi-nosinusitis, seizures, metabolic disturbances,infection, sepsis, meningitis, brain abscess,recurrence and death were noted.

Results: Eleven patients were identified. 9 were femaleand 2 were male. The average age was 50.The average BMI was 43.7 Kg/m2. CSF rhinor-rhea was the most common presenting symp-tom (82%). The meningoencephalocele wasright-sided in 3 patients (27%) and left-sided in8 patients (73%). The average size was 0.5cm2. 5 patients (45%) had a lumbar drainplaced. Neurological complications includedintraparenchymal hemorrhage (1/11) resulting inseizure, hemipalatal hypesthesia (2/11) andheadaches (6/11). Ocular complications werelimited to dry eyes (5/11), which improved in 3patients. Acetazolamide was used in 9 patients,3 of which developed electrolyte disturbances.There were no cases of sepsis, meningitis orbrain abscesses. The average duration of fol-low-up was 18 months (range 5-42). The overallsuccess rate was 100%.

Conclusion: The transpterygoid approach represents a high-ly effective and low-morbidity/mortality tech-nique to repair LRS meningoencephalocelesand CSF leaks.

Poster# P-38Pedicled Mucochondral Nasoseptal Flap forReconstruction of Orbital Floor DefectEvelyne Kalyoussef, MD, James K. Liu, MD,Jean Anderson Eloy, MDNewark, New Jersey USA

Introduction: Repair of orbital floor defects is imperative forsupport of orbital contents and prevent herniationinto the maxillary or ethmoidal sinuses whichmay lead to atrophy of orbital tissues, enopthal-mos or hypoglobus resulting in diplopia.Materials traditionally used for orbital floordefects repair include prosthetic implants andalloplastic or autogenous material. Nasal septalcartilage has been used previously as a freegraft for reconstruction, however it relies on localtissue for its blood supply and may becomeischemic and necrose in the postoperative peri-od. The vascularized pedicled nasoseptal flap,consisting of mucoperichondrium and mucope-riosteum, is routinely used as an effective flap forskull base and dural reconstruction. We reportthe first case of using a pedicled mucochondralnasoseptal flap.

Method:A fifty-two year old male with malignant periph-eral nerve sheath tumor of the left maxilla andorbital floor underwent combined open andendoscopic tumor resection, resulting in a largeorbital floor defect. Due to the expected needfor postoperative radiation therapy and the riskof graft protrusion with synthetic material use ofan autogenous graft with robust blood supplyand inherent structural strength was sought.

Results: A pedicled muchochondral nasoseptal flap con-sisting of ipsilateral nasoseptal mucosa andquadrangular cartilage was harvested and wassuccessfully used for the repair. The patient didwell postoperatively without complications.

Conclusion: The pedicled muchochondral nasoseptal flapprovides a vascularized flap with intrinsic carti-laginous support and mucosal lining. It offers anew technique for reconstruction of orbital floordefects and perhaps bony skull base defec


Poster# P-39Pituitary adenoma extending into theparanasal sinusesTakahiro Suzuki, MD, Yasuyuki Hinohira, MD,Harumi Suzaki, MDTokyo, N/A Japan

Objective:Pituitary tumor is one of common brain tumors.Extrasellar extension into the paranasal sinusesis infrequent, and that may have malignancy. Werecently experienced three cases of pituitaryadenoma extending into the paranasal sinusesoperated on with neurosurgeons. We showedthe details of surgery of the cases and discussedabout the respective roles in cooperation of ENTand neurosurgeons.

Cases:Three cases with pituitary adenoma weredemonstrated.

Results:Case1: 72 years old female complained of visu-al disturbance caused by recurrent pituitaryadenoma extending into the right sphenoidsinus, the maxillary sinus and the pterygopala-tine fossa. ENT surgeons first removed thetumor in the paranasal sinuses with use ofendoscope, and then neurosurgeon removedthe residual tumor in the sella turcica with useof microscope.Case2: 73 years old female. The tumor like thesphenoid tumor existed in both sphenoid sinus-es. ENT surgeons took biopsy samples fordiagnosis, and then neurosurgeons removedthe tumor.Case 3: The tumor involved the carotid artery inthe left sphenoid sinus. ENT surgeons providedneurosurgeons with visuality using endoscopeand neurosurgeons removed the tumor.

Conclusion:ENT surgeons remove the tumor in theparanasal region and neurosurgeons do in thesella turcica. Cooperation of both surgeons invisuallity and manipulation is significant.

Poster# P-40Postoperative Cerebrospinal Fluid Leak afterSeptoplasty: A Potential Complication ofOccult Anterior Skull Base EncephaloceleResha S Soni, BS, Qasim Husain, BS, SaurinSangvhi, BS, James K Liu, MD, Jean AndersonEloy, MD, FACSNewark, NJ USA

Introduction:Postoperative CSF rhinorrhea after septoplastyis a known entity resulting from errors in surgi-cal technique and improper handling of the per-pendicular plate of the ethmoid bone. Whenthese occur, urgent management is necessaryto prevent deleterious sequelae such as menin-gitis, intracranial abscess, and pneumo-cephalus. In this report, we present a case ofCSF rhinorrhea occurring 2 weeks after septo-plasty from manipulation of an occult anteriorskull base encephalocele.

Methods:Case report.

Results:A 67-year-old obese female was referred to ourtertiary-care center for profuse left-sided rhinor-rhea beginning two weeks after a septoplastyand bilateral inferior turbinate reduction. Nasalendoscopy revealed bilateral nasal crusting anda mid septal perforation. CSF leakage was con-firmed by a positive ß2-tranferrin testing.Paranasal sinus CT scan was suspicious for abony defect of the roof of the left sphenoidsinus. The encephalocele was cauterized usingendoscopic bipolar. The area around theencephalocele was demucosalized and cauter-ized to prevent postoperative intracranial muco-cele formation. The skull base defect wasrepaired using thick acellular dermal allograft(ADA) (LifeCell Corporation, Branchburg, NJ)intracranially followed by an overlay of middleturbinate mucosal autograft. The repair wassubsequently bolstered by multiple large piecesof gentamicin-soaked Gelfoam.

Conclusion:Encephaloceles are rare occurrences charac-terized by herniation of intracranial contentsthrough a skull base defect. Although manycases of CSF rhinorrhea following septoplastyoccur due to iatrogenic alteration of the cribri-form plate, otolaryngologists should considerthe possibility of a previously undiagnosedencephalocele in their differential diagnosis.


Poster# P-41Pre-operative predictors for intra-operativeblood loss in endoscopic surgery forsinonasal malignancyJohn J Chi, MD, Jeffrey Suh, MD, Alexander G Chiu, MD, James N Palmer, MD,Vijay R Ramakrishnan, MDPhiladelphia, PA USA

Background:Endoscopic resection of sinonasal malignancyhas become gradually accepted in carefullyselected cases. Endoscopic tumor resectionoften requires rapid initial tumor debulking,which may be associated with significant bloodloss. If anticipated, surgical maneuvers can beperformed to limit hemorrhage, such as arterialligation or use of a coblator. The purpose of thisstudy was to identify pre-operative predictivefactors for intra-operative blood loss in surgeryfor sinonasal malignancy.

Methods:A retrospective chart review was performed of70 patients who underwent endoscopic resec-tion of sinonasal malignancy at tertiary careinstitutions from 2002 to 2012. Patient datawere collected on presenting symptoms, med-ical co-morbidities, radiographic features, pre-operative hemoglobin level, operative details,tumor histology and stage, post-operativecourse, and need for transfusion.

Results:The most common tumor types were adenocar-cinoma, melanoma, esthesioneuroblastoma,and squamous cell carcinoma, respectively.Preoperative complaint of epistaxis was expect-ed to be the most relevant factor, however therewas no difference in intraoperative blood lossbetween tumor patients with and without preop-erative epistaxis (490 vs 531 mL, respectively;p=0.822). No significant statistical differencewas identified in the other preoperative factorsexamined.

Conclusion:For patients undergoing endoscopic resectionof sinonasal tumors, it can be challenging topredict the degree of blood loss expected. Thesurgeon should be prepared to perform neces-sary maneuvers to minimize blood loss in orderto facilitate meticulous dissection and reducethe need for transfusion.

Poster# P-42Quality of surgical field during endoscopicsinus surgery: A systematic review of theeffect of total intravenous anesthesia com-pared to inhalation anesthesiaElizabeth Kelly, MD, Suneeta Gollapudy, MD,Matthias Riess, MD, PhD, Harvey Woehlck,MD, David Poetker, MD, MAMilwaukee, WI USA

Background:Adequate surgical field visualization is impera-tive for successful outcomes in endoscopicsinus surgery (ESS). The type of anestheticadministered can alter a patient's hemodynamicparameters and impact endoscopic visualizationduring surgery. The aim of this study is toreview the evidence regarding the effect of totalintravenous anesthesia (TIVA) compared toinhalational anesthesia (INA) on visualization ofthe surgical field during ESS.

Methods:A systematic review of the literature was per-formed. Ovid MEDLINE, Scopus, and Cochranedatabases were searched from 1946 to January2012. Citations from the primary search werereviewed and filtered to identify all relevantabstracts in English. Articles meriting full reviewincluded prospective controlled trials enrollingadult patients undergoing endoscopic sinus sur-gery that were randomized to a group receivingINA or TIVA with outcome measures thatfocused on surgical field visualization.

Results:Seven eligible trials fulfilled inclusion criteria.Four of the seven articles demonstrated a statis-tically significant improvement in surgical fieldgrade during ESS when receiving TIVA com-pared with INA. Detailed INA dosages were oftennot provided. High levels of INA may have beenadministered; therefore, side effects of INA ratherthan effects of an ideal INA administration werepossibly represented. Analgesic administrationalso varied among the anesthetic groups furthercomplicating interpretation of study results. Thelack of power and the heterogeneity of the stud-ies precluded a formal meta-analysis.

Conclusions:The majority of current evidence suggests TIVAmay improve surgical conditions in ESS, how-ever there are significant limitations with thesestudies and need for further study.


Poster# P-43Rhinoplasty and psychopathologic symp-toms relationshipMohsen Naraghi, MD, Razieh Adabi Mohazab, MDTehran, Tehran Iran

Purpose: 1) To evaluate whether candidates of aestheticnose surgeries show more psychopathologiesthan other patients undertaking non cosmeticsurgeries. 2) To assess psychopathologicsymptoms in patients seeking rhinoplasty

Methods: The symptom check-list- 90-revised (SCL-90-R)was used to evaluate current psychopatholo-gies in candidates of rhinoplasty and otherotorhinolaryngology surgery patients. Theanswers are evaluated in 9 primary symptomdimensions: Somatization, ObsessiveCompulsive, Interpersonal sensitivity,Depression, Anxiety, Anger -Hostility, PhobicAnxiety, Paranoid Ideation and Psychoticism.Data were analyzed through chi-square, stu-dent t-test and one- way ANOVA.

Results: The male candidates of rhinoplasty had signifi-cantly more previous history of trauma to nosethan females (P: 0.046). Within the rhinoplastycandidates 63.9% showed at least one patho-logic primary symptom (scale>= 1) with femalesbeing involved more than males (P: 0.024). Inother otorhinolaryngology surgery patients,70.3% had at least one pathologic primarysymptom, while no significant difference wasobserved within the two sexes (p: 0.51). Thefrequency of pathologic symptoms in rhinoplas-ty and other surgery groups was not different(P: 0.56). The most frequent symptom in bothgroups was paranoid ideation and the least fre-quent one was psychoticism. Psychopathology(score>=3) was observed as paranoid ideationin one patient of control group.

Conclusions:The assessment of psychopathologic symptomsin cosmetic surgeries patients has reportedcontroversial data due to previous studies.Even though the present study reveals no sig-nificant differences of psychological symptomsbetween rhinoplasty and non- cosmetic patientsof otorhinolaryngology, the data shows thatfemale rhinoplasty candidates are more psy-chologically pathologic than male candidates.

Poster# P-44Selective Middle Turbinectomy to MinimizePostoperative Obstruction Following LesterJones Tube PlacementDeepa V Cherla, BS, Osamah J Choudhry, MD,Jean Anderson Eloy, MD, FACSNewark, NJ USA

Introduction: Conjunctivodacryocystorhinostomy (CDCR) withthe insertion of a Lester Jones (LJT) tube is asurgical procedure used to relieve epiphoracaused by upper lacrimal system dysfunctionfrom extensive proximal canalicular obstruction,canalicular stenosis, or canalicular flaccidity.Jones tube obstruction, which is the secondmost frequent complication of CDCR with tubeplacement, can result from LJT placementagainst the anterior end of the middle meatus.In this study, we describe our results in 3patients who underwent selective anterior/supe-rior middle turbinectomy after LJT obstruction.

Methods: A retrospective analysis was performed on 3patients with LJT obstruction from contactagainst the anterior/superior middle turbinate.Selective middle turbinectomy was performed inall 3 patients. Patency of the LJT was assessedsymptomatically and by nasal endoscopy at thelatest follow-up.

Results: All 3 patients displayed a patent LJT after amean follow-up of 17.3 months without compli-cations. Longer-term complications associatedwith CDCR with LJT placement, including con-tinuous epiphora, dacrocystitis, and poor patientsatisfaction, were not observed.

Conclusions: Selective anterior/superior middle turbinectomymay prevent or relieve LJT obstruction, provid-ing for increased room along the lateral nasalmucosa along which to place the LJT anddecreasing the need for further surgeries aris-ing from LJT blockage.


Poster# P-45Self-esteem status in rhinoplasty and non-cosmetic surgery patientsMohsen Naraghi, MD, Razieh Adabi Mohazab, MDTehran, Tehran Iran

Purpose: 1) To understand if rhinoplasty candidates sufferfrom lower self-esteem than those undertakingnon cosmetic surgeries. 2) To compare thestate of self-esteem in rhinoplasty and non-cos-metic surgical patients.

Methods:The Rhosenberg's self -esteem scale was eval-uated in two separate groups, candidates ofrhinoplasty and non-cosmetic surgeries inotorhinolaryngology. Overall 10 questionsscored from 0 to 30, the scores bellow 15 sug-gests low self -esteem. 90 patients were askedto answer the inventory pre-operatively and thedata was analyzed through chi-square and stu-dent t- test.

Results: Overall 54.4% of female patients, 62% were inrhinoplasty group (p: 0.02). The meanRhosenburg scale in rhinoplasty seekers was22.16 with 4.5% showing low self- esteem (<15), while with the mean rhosenburg scale of20.82, 15.6% of non-cosmetic surgical patientsrevealed low self -esteem (P: 0.15). Althoughnone of the male rhinoplasty candidates hadlow self- esteem, there was no significant differ-ence in Rhosenburg scales within the two gen-ders (P: 0.44) . Non-cosmetic otorhinolaryngol-ogy surgery female patients had significantlylower self-esteem (P: 0.03).

Conclusions: The previous data on the self- esteem of cos-metic surgeries candidates had reported lowerself- esteem in this group with an emphasisover the female patients. Based on the presentstudy the overall self- esteem scores of rhino-plasty patients was not different of the otherpatients of otorhinolaryngology surgeries. Thefemale rhinoplasty candidates did not showlower self- esteem than the males. Interestinglytheir overall self- esteem was significantly high-er than the other female patients.

Poster# P-46Single Center Experience with a NovelChitosan-PEG Nasal PackingNadim B Bikhazi, MDOgden, UT USA

Introduction:The optimal form of nasal packing after endo-scopic sinus surgery still remains elusive. Thegoal of packing is adequate hemostasis, adhe-sion control by tissue separation, and patientcomfort. This poster presents the experience ofa single center with a novel chitosan-polyethyl-ene glycol (PEG) derivative designed to com-bine tamponade with inherent hemostatic capa-bility, to provide a durable stenting effect duringhealing, and to elicit desirable degradationcharacteristics.

Methods:Eight patients were treated with the chitosan-PEG nasal packing following nasal surgery (14placements; 6 bilateral, 2 unilateral). The nasalpacking was placed at the surgical site dry, thenhydrated with sterile saline to expand the pack-ing and maintain its position. Patients returnedfor a follow-up evaluation 5-8 days after theprocedure and were visually inspected for thepresence of the chitosan-PEG nasal packing,adhesion formation, and mucosal healing.

Results:No scarring or adhesion formation wasobserved in any of the 14 placements. The chi-tosan-PEG packing had completely degraded in6/14 nasal packs. Small, isolated portions ofthe packing were observed in the remaining tar-get locations. The soft, mucus-like remnantswere left in place or removed via gentle aspira-tion. There were no reports of the packingmigrating away from the surgical site or patientdiscomfort following the procedure.

Conclusion:The chitosan-PEG packing prevented adhesionbetween tissues following nasal surgery, waseasy to handle and manipulate during place-ment, substantially degraded by the follow-upvisit, and did not cause any patient discomfort.


Poster# P-47Sinus Atelectasis as long-term complicationof rhinoplastyMohsen Naraghi, MD, Shabnam Mortazavi,MD, Massoud Boroojerdi, MD, NazaninHajarolasvadi, MDTehran, Tehran Iran

Maxillary sinus atelectasis or silent sinus syn-drome is a rare clinical entity that progressesgradually due to the osteomeatal complexobstruction. Ostiomeatal blockage due to thedamage of this complex is the most possiblecause of maxillary sinus atelectasis. The termsilent sinus syndrome was defined as unilateralprogressive enophtalmos secondary to themaxillary sinus opacification.

We present four patients developed chronicsinus atelectasis after septorhinoplasty. Therehas been only one prior report of sinus atelecta-sis presenting after rhinoplasty. Despite of thisprior report, sinus atelectasis in our four patientsis a first report of delayed sinus atelectasis fol-lowing rhinoplasty that all were developed morethan one year after procedure. Lateral displace-ment of the end part of middle turbinate results inobstruction of the ostiomeatal and accumulationof secretions in closed sinus cavity. All of thepatients had nasal dressing after surgery. Ourhypothesis is that the nasal dressing followingrhinoplasty may lead to lateralization of the endof middle turbinate. Delayed sinus atelectasiscan be a potential missed complication of sep-torhinoplasty which may present several yearsafter surgery

Poster# P-48Sinus Headache: Rhinogenic Headache orMigraine? An Evidence Based Guide toDiagnosis and TreatmentZara M Patel, MD, David W Kennedy, MD,Michael Setzen, MD, FACS, FAAP, David MPoetker, MD, MA, John M DelGaudio, MDAtlanta, GA USA

Background: Patients present to physicians across multipledisciplines with the complaint of “sinusheadache”. This lay term is widely accepted inthe media, yet has been repeatedly questionedin the medical literature, and experts in the fieldsof otolaryngology, neurology, and allergy haveagreed that it is an overused and often incorrectdiagnosis. There are review articles and consen-sus panels regarding this issue, but thus far noguidelines based purely on a review of the levelof evidence provided by the literature.

Methods: A systematic review of the literature was per-formed and the Clinical Practice GuidelineManual, Conference on GuidelineStandardization (COGS), and the Appraisal ofGuidelines and Research Evaluation (AGREE)instrument recommendations were followed.Study inclusion criteria: adult population >18years old, self-diagnosed or physician-diag-nosed "sinus headache", clearly defined diag-nostic criteria in diagnostic studies, and clearlydefined primary clinical end-point in therapeuticstudies.

Results: We identified and evaluated the literature ondiagnosing and treating patients with a primarycomplaint of sinus headache. The literaturewas reviewed for both quality of researchdesign as well as benefit and harm of the pro-posed interventions.

Conclusions: If a thorough neurologic and otolaryngologicevaluation is performed, the majority of patientspresenting with sinus headache in the absenceof acute inflammatory findings will be diagnosedwith migraine. In this situation, the appropriatetreatment for the majority of patients presentingwith "sinus headache" is migraine directed ther-apy. In a highly select group of patients, direct-ed nasal surgery addressing endonasal contactpoints may be an option.


Poster# P-49Spontaneous CSF leak repair: A five yearprospective evaluationMohamad R Chaaban, MD, Bradford AWoodworth, MD, Kristen O Riley, MDBirmingham, AL USA

Introduction: Mounting evidence indicates the majority ofspontaneous cerebrospinal fluid (CSF) leaksare associated with intracranial hypertension.The objectives of the current study were toassess outcomes regarding spontaneous CSFleaks focusing on premorbid factors, surgicaltechnique, and management of intracranialpressure.

Methods: Prospective evaluation of patients with sponta-neous CSF leaks was performed. Data regard-ing demographics, nature of presentation, bodymass index (BMI), location and size of defect,intracranial pressure, clinical follow up, andcomplications were collected.

Results: Over 5 years, 42 patients (avg. age 51) with 48spontaneous CSF leaks were treated by a singleotolaryngologist. Twenty subjects presented withrecurrence of their CSF leak following previousendoscopic and/or open approaches by otherphysicians. Obesity was present in 79% of indi-viduals (average BMI 36). Forty-four CSF leaks(92%) were successfully repaired at first attempt.With secondary repair, all CSF leaks were closedat last clinical follow-up (average 22 months).Three patients developed late failures (>2months) with one recurrence at a distinct locationfrom the primary site at 8 months post procedure(associated with ventriculoperitoneal shunt fail-ure). Opening pressures via lumbar punctureaveraged 22.8+/-7.5 cmH20, which significantlyincreased to 31.9+/-10.4 cmH20 (p<0.0001) fol-lowing closure of the skull base defect(s).Management of intracranial hypertension includ-ed acetazolamide or permanent CSF diversion in16 patients (5 revisions of failed pre-existing ven-triculoperitoneal shunts).

Conclusions: While spontaneous CSF leaks have the highestrecurrence rate of any etiology, prospectiveevaluation demonstrates high success rateswith control of intracranial hypertension.

Poster# P-50Subepithelial intracellular bacterial biofilmsin nasal polyps - a novel findingStephen M Hayes, MD, Luanne Hall-Stoodley,PhD, Salil B Nair, MD, Philip Harris, MD, SaulFaust, MD, Rami J Salib, MDSouthampton, Hampshire United Kingdom

Objectives: Chronic rhinosinusitis (CRS with and withoutpolyps) affects up to 15% of the UK population.Recent studies have identified bacterial biofilmson the sinonasal mucosal of patients with CRS.However, there is little precedent in the litera-ture characterising bacterial biofilms in nasalpolyps. We, therefore, conducted a study tocompare bacterial biofilms in nasal polyps withthose in sinonasal mucosa from patients withCRS with polyps.

Methods: A prospective study of 8 patients undergoingendoscopic sinus surgery for CRS with polyps,and 2 control patients undergoing trans-sphe-noidal pituitary surgery. Uncinate mucosa andpolyp were obtained and assessed for bacterialbiofilms using Fluorescence in situHybridisation and imaging with Confocal LaserScanning Microscopy.

Results: In all CRS cases, bacterial biofilms were identi-fied on the epithelial surface of uncinatemucosa. No biofilms were identified on the sur-face of polyps or control mucosa. However, inall polyps, bacterial biofilms appeared to besub-epithelial, intracellular and not attached tothe epithelial surface.

Conclusion: The identification of sub-epithelial, intracellularbacterial biofilms in nasal polyps is not only anovel finding but also challenges the concept ofbiofilms being always attached to a surface. It ispossible that in a drive for survival, biofilms mayhave developed a host-cell 'parasitic' abilityallowing concealment from host defences. Weare currently in the process of identifying thesebiofilm-containing cells. These study findingsshed light on the role of bacterial biofilms in thepathogenesis of nasal polyps, and may helpexplain the recalcitrant nature of the disease.


Poster# P-51Survey of 253 patients with nasal fractureMohsen Naraghi, MD, Babak Saedi, MD,Mahsa Abbaszadeh, MD, HamidrezaSeifmanesh, MDTehran, Tehran Iran

Objectives: Nasal fracture can result in psychological andfunctional outcomes and may have impact ongeneral quality of life. Here we studied ourpatients with nasal fracture during two consecu-tive years in our center.

Methods: 253 patient enrolled in the study during two-year period. Demographic data, clinical featuresand radiological findings were recorded. Weassessed level of satisfaction in terms of nasalobstruction and nasal appearance using VisualAnalogue Scale (VAS).

Results: Totally, 235 patients were enrolled. The meanage was 23.5 ± 12.5 year (range 1 to 69) and75.3% were male. Assault (34.5%), falling down(23.4%), sport injuries (17%), motor vehicleaccidents (13.2%) and casual damage byheavy objects (11.9%) were the etiologies ofnasal bone fracture, respectively. 97% of allcase had lateral nasal fracture and 38.7% hadseptal deviation. VAS was recorded for 180patients and its mean was 8.7±1.8 for nasalobstruction and 9.1±1.8 for nasal appearance(male > female, P=0.06). Those with nasalbone fracture due to assault and motor vehicleaccident more seek forensic doctor (P<0.001).

Conclusion:Changing the appearance of the nose and painwere the most common clinical feature amongstmen and women, respectively. Individuals withhistory of previous nasal bone fracture aremore prone to second nasal bone fracture. Nosignificant relation was found between satisfac-tion and age, sex and type of anesthesia.

Poster# P-52The bacteriology of chronic rhinosinusitisand the pre-eminence of Staphylococcusaureus in revision patients.Edward J Cleland, MBBS, Ahmed Bassiouni,MBBCh, Peter-John Wormald, MDWoodville, South Australia Australia

Background:The role of bacteria in the aetiopathogenesis ofchronic rhinosinusitis (CRS) remains an area ofinterest. The impact of surgery and factors suchas nasal polyposis, asthma and aspirin sensitiv-ity on the bacterial state are not completelyunderstood. This study examines the cultureresults from a large cohort of CRS patients toshed light on these questions.

Methods:This retrospective study utilised the cultureresults from 513 CRS patients, which wereanalysed for species growth and compared todemographic factors such as previous surgery,presence of polyps, aspirin sensitivity and asth-ma. Univariate and multivariate logistic regres-sion models were utilised for statistical analysis.

Results:83% of patients had a positive culture result.The average number of isolates detected perpatient was 0.95. S. aureus was the most fre-quently cultured organism, found in 35% ofpatients, followed by P. aeruginosa (9%),Haemophilus spp. (7%) and S. pneumonia(5%). Revision patients were significantly morelikely to grow S. aureus (P = 0.0009), P. aerugi-nosa (P = 0.0436) and have a positive culture(P = 0.005). Asthma was correlated with a posi-tive culture (P = 0.0392). No significant differ-ence was determined between polyp and non-polyp groups for any of the bacterial outcomes.

Conclusion:This study highlights important factors in the bac-teriology of CRS patients. S. aureus was themost prevalent species identified followed by P.aeruginosa. S. aureus rates of isolation werealso significantly higher in patients undergoingrevision surgery. No association was foundbetween the presence of nasal polyposis andculture rates.


Poster# P-53The Central Onodi Cell: A PreviouslyUnreported Anatomic VariationDeepa Cherla, BS, Saurin Sanghvi, BS,Qasim Husain, BS, Senja Tomovic, MD,James K Liu, MD, Jean Anderson Eloy, MD,FACSNewark, NJ USA

Introduction: While the endoscopic endonasal transsphe-noidal route provides a minimally invasiveapproach and wide field of view for removal ofsellar and parasellar lesions, a thorough knowl-edge of sphenoid sinus anatomy is necessaryto avoid complications. These include arterialhemorrhage, visual loss, and cranial nerve andextra-ocular muscle palsies. The best radi-ographic tool to analyze the sphenoid sinus andits surrounding structures is the computedtomography (CT) scan.

Methods:A case report.

Results: Preoperative CT scan demonstrated a centralethmoid air cell posterior to the anterior face ofthe sphenoid sinus. The central Onodi cell wasidentified through an endoscopic endonasalapproach in a position superior to the sphenoidsinus with bilateral optic nerve bulging. Thepatient did well postoperatively with improve-ment in her headaches and no vision changesor CSF leak.

Conclusion: The central Onodi cell is an overriding posteriorethmoid cell that lies superior and midline to thesphenoid sinus and in close association withthe optic nerve. Preoperative recognition of theOnodi cell is necessary to avoid injury to closelyassociated structures, including the internalcarotid artery and the optic nerve, as well asidentify structures that may interfere with expo-sure of the sellar floor or increase patient sus-ceptibility to sinusitis.

Poster# P-54The effect of nasal saline irrigation on olfac-tion: A prospective randomized trial.Jack J Liu, MD, Guy C Chan, PhD, Avi S Hecht,MD, Daniel R Storm, PhD, Greg E Davis, MDSeattle, WA USA

Introduction: Nasal saline irrigation is a safe adjunct treat-ment for chronic rhinosinusitis; however, itseffect on olfaction is unclear. Cyclic AMP(cAMP) is a key second messenger in themechanism of olfaction and has been shown tobe associated with smell function. In animalstudies, olfactory cilia are harvested by simplesaline washes. This study aimed to characterizethe effect of nasal saline irrigation on smellfunction.

Methods: Volunteers with normal olfaction were random-ized into a control or irrigation cohort. In the ini-tial appointment, subjects completed aUniversity of Pennsylvania Smell IdentificationTest (UPSIT) and nasal samples were obtainedby 2 methods, the nasal curette and cytobrush.The irrigation cohort performed daily nasalsaline irrigations. Both cohorts then returned in1 week. The UPSIT and nasal cell collectionwere repeated, and each subject completed asubjective olfactory transition scale. Nasal sam-ples were processed for cAMP levels using acommercial ELISA assay.

Results: 30 subjects were enrolled and randomized intoeach cohort. Pre- and post-irrigation meanUPSIT scores were 36.4 and 36.7 (P=0.52). Nosubjects reported a subjective smell loss. Tenpairs of nasal samples were assayed. Using thecurette, pre- and post-irrigation cAMP levelswere 539 and 497 (p=0.17). Using the cyto-brush, respective cAMP levels were 519 and455 (p=0.13).

Conclusion: Nasal saline irrigation has no subjective orobjective effect on olfaction. It also does notappear to affect cAMP levels, a potential mark-er of smell function.


Poster# P-55The Incidence of Diabetes Insipidus inEndoscopic Pituitary SurgeryArjuna Kuperan, MD, Kaashif Eazazuddin,DO, Anderson Eloy, MD, James K Liu, MDNewark, NJ USA

Introduction:Diabetes insipidus(DI) is a well known compli-cation of endoscopic pituitary surgery especiallywith extended approaches and craniopharyn-giomas. Both transient and permanent DI,defined as less than and greater than 6 monthsrespectively, result in a prolonged hospitalcourse, patient morbidity, and in some casesindefinite treatment. The purpose of this studyis to perform an institutional review of all endo-scopic pituitary surgery, the frequency of tran-sient and permanent diabetes insipidus, andcompare it to other large series.

Methods: Retrospective review of a single tertiary carecenter

Results: Overall, there were 70 endoscopic pituitary sur-geries performed between January 2009 andJune 2012, and 10 of these were craniopharyn-giomas. The overall, transient, and permanentrates of DI were 21.4%, 10%, and 11.4%. Inthe craniopharyngioma group the equivalentrates were 90%, 40%, and 50%. Removingcraniopharyngiomas from the total group the DIrates were 10%, 5%, and 5%. All cases of DIwith pituitary adenomas involved extendedendoscopic approaches.

Conclusions:Our results with adenoma resection are compa-rable to other large published series. The over-all rates of DI and those rates among only cran-iopharyngiomas are difficult to compare as aresult of sparse parallel data. Further datamust be collected in order provide meaningfulcomparisons between subgroups such as cran-iopharyngiomas and adenomas.

Poster# P-56The Many Faces of The Balloon: A NewTreatment For Acquired NasopharyngealStenosisDevars du Mayne Marie, Fellow, WoodsOwen, Resident, Desrosiers Martin, MDMontreal, Quebec Canada

Objective: We describe our use of balloon dilation to treatan acquired nasopharyngeal stenosis (NPS) fol-lowing radiotherapy. A 62-year-old patient treat-ed by chemo/radiotherapy for a T4N2M0nasopharyngeal carcinoma presented with com-plete bilateral nasal obstruction ten monthsafter radiotherapy. Endoscopic examination andsinus CT confirmed the stenosis. Recurrencewas excluded after histological examination. Inthe literature, proposed therapeutic optionsassociate various combinations of local flaps,laser excision, application of mitomycin-C andnasal stenting. Although these therapies can beefficient, they remain invasive and do not pre-vent the high risk of recurrence (33 %). Thismotivated us to attempt a new, potentially lessaggressive procedure using only the balloondilation to relieve the stenosis.

Method: A small passage in the stenosis was cannulatedusing a rigid probe and a Nelaton catheter andused to pass a 12mm oesophageal dilation bal-loon, which was then inflated, to 12 ATM. Theprocedure was performed under general anes-thesia under videoendoscopic control.

Results:The result was immediate, with complete reliefof the stenosis, which respected the mucousmembrane. At one-month post-operative follow-up, nasal breathing was greatly improved, withendoscopic examination confirming a goodfunctional result, showing a widely patentnasopharynx without mucosal scar.

Conclusion:Transnasal balloon dilation may represent arapid, safe, noninvasive, and effective treatmentof NPS. Even if current follow-up period isinsufficient to estimate its long-term efficiency,balloon dilation appears to be a atraumatictechnique for both the mucosal membrane andthe patient, which makes it easily repeatable incase of recurrence.


Poster# P-57The prevalence of Osteitis in the Uncinateprocess in CRS patients versus controls.Peter J Catalano, MD, Meir Warman, MD, RahulC Gupta, MD, Rohan C Wijewickrama, MDBoston, MA USA

Introduction: Chronic rhinosinusitis (CRS) is a commoninflammatory condition with multiple etiologies.Osteitis of the underlying bone, and in particu-lar, the uncinate process (UP) is postulated asone of the main causes for CRS. The preva-lence of bone remodeling changes in the unci-nate process (UP) of healthy controls has notbeen previously examined.

Objectives: The objectives of this study were to determineand compare the prevalence of osteitis of theuncinate bone in patients with CRS versushealthy controls.

Methods: Prospective histopathologic examination of theUP/uncinate bone was performed to identifyosteitis in the study group (patients undergoingsinus surgery for CRS) versus a similar-sizedcontrol group. The presence of osteitis wasdetermined as bone remodeling and the forma-tion of woven bone using polarized lightmicroscopy.

Results: A total of 20 consecutive uncinate bones wereexamined. 10 from patients with CRS and 10from the control group. The mean age ofpatients was 43 and 44 years in the two groups.Pathologic evidence for osteitis was found in50% of the CRS patients and 30% of the con-trol 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 oteitis of the UP asa significant factor in the pathogenesis of CRS.This preliminary data needs to be further evalu-ated in large scale CRS and healthy popula-tions.

Poster# P-58Uncinate-Preserving Transnasal Cannulationand Dilation of the Natural Maxillary Ostiumin a Cadaveric ModelDavid Brodner, MD, Ian Alexander, MD, William Brown, MD, Stephen Chandler, MD,Kapil Saigal, MD, Jeffrey Cutler, MDBoynton Beach, FL USA

Background:Guide catheter and guidewire-assistedtransnasal balloon placement during maxillarysinus ostial dilation was reported to create falsepassages through the maxillary fontanelle.Accuracy of transnasal dilation of the naturalmaxillary ostium was evaluated following proce-dure training for a malleable-tipped multi-sinusballoon device.

Methods:Transnasal cannulation and dilation of 42cadaveric maxillary sinus ostia was attemptedby six surgeons including three with very limitedclinical experience using the device. All physi-cians received procedure training per the studyprotocol that included shaping the malleable-tipped balloon device into the recommend max-illary configuration of 135 degrees. Tissue dis-section was prohibited. Canine fossa trephina-tion and transantral endoscopy evaluated can-nulation and dilation outcomes. Physician oper-ators were blinded to transantral images andresults were filmed and documented by twoindependent reviewers.

Results:Appropriate transnasal cannulation and dilationof natural maxillary sinus ostia occurred in92.9% (39/42) of attempts. Two failuresemanated from procedural deviations. In onedeviation, the bend angle was changed to 90degrees and the device tip did not cannulatethe ostium. In the second, the device waspassed through a pre-existing hole in the unci-nate and cannulated the natural ostium. A thirdfailure occurred when the device was passedthrough the fontanelle creating a false lumen.When protocol procedural techniques wereused, the success rate was 97.5% (39/40).

Conclusion: Using recommended proceduraltechniques and a malleable-tipped balloondevice, newly trained and experienced physi-cians alike can perform uncinate-preservingtransnasal cannulation and dilation of the maxil-lary ostium with a high rate of success.

COSM 2013April 10-14, 2013

JW Marriott Grande Lakes, Orlando, Florida

For further information, please contact:Wendi Perez, ARS Administrator, American Rhinologic Society, PO Box 495, Warwick, NY 10990

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

www.american-rhinologic.org

COSM 2013, April 10-14, 2013 - Orlando, FLARS Summer Sinus Symposium, July 19-20, 2013 - Chicago, IL

59th Annual Meeting of the ARS, September 28, 2013 - Hyatt Regency Vancouver, Vancouver, BCCOSM 2014, May 14-18, 2014 - Las Vegas, NV

Submit your abstract online: www.american-rhinologic.orgSubmit your manuscript online: http://mc.manuscriptcentral.com/alr

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