american rhinologic society

AMERICAN RHINOLOGIC SOCIETY

49th Annual Spring Scientific MeetingMay 2 – 6, 2003

Nashville, Tennesse

Objectives: This program has been assembled to fulfill the edu-cational needs of the membership of the American RhinologicSociety based partly on feedback from last year’s meeting, aswell as on conversations among the various members of theBoard of Directors and Counselors.

From a large number of submitted abstracts the very best wereblindly selected for presentation with a goal, however, to fulfillthe perceived educational needs of the membership.

In addition, special panels were put together to augment theproper papers with the same goal in mind.

Commercial Support: This scientific program has been partiallysupported by unrestricted educational grants from Aventis Phar-maceuticals, Glaxo, Wellcome, Schering Pharmaceuticals, BayerPharmaceuticals, Bristol-Myers Squibb Co., Karl Storz Endos-copy-America, Inc., Medtronic Xomed, Ortho-McNeil, Smith &Nephew-ENT, Surgical Laser Technologies, VisualizationTechnology, Inc., Linvatec, Richard Wolf Medical InstrumentsCorporation.

As an accredited sponsor of CME activities, the AmericanRhinologic Society has adopted the standards of the ACCMEand formulated a policy with regard to commercial support ofeducational activities. This educational program has been pre-pared in accordance with these standards and policies.

DISCLOSURE STATEMENT: In accordance with the policies ondisclosure of the Accreditation Council for Continuing MedicalEducation and the Program/Education Advisory Committee ofthe American Rhinologic Society, presenters for this programhave identified no personal relationships which, in the contextof their topics could be perceived as a real or apparent conflict ofinterest. Those presenters who have identified any relationshipswith a commercial concern will announce the nature of that rela-tionship at the meeting prior to their presentation.

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AMERICAN RHINOLOGIC SOCIETY

Officers and Board of Directors2002-2003

PresidentDonald C. Lanza, MD

President ElectJames A. Hadley, MD

SecretaryMarvin P. Fried, MD

TreasurerDavid Kennedy, MD

Immediate Past PresidentPaul H. Toffel, MD

Past PresidentFrederick A. Kuhn, MD

First Vice PresidentJoseph B. Jacobs, MD

Second Vice PresidentMichael J. Sillers, MD

Board of DirectorsWilliam E. Bolger, MDMartin J. Citardi, MDScott M. Graham, MDStilianos E. Kountakis, MD, PhDThomas V. McCaffrey, MDRobert M. Meyers, MD

Consultants to the BoardDaniel G. Becker, MDPeter H. Hwang, MDSteven C. Marks, MDEugenia M. Vining, MD

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2002 Corporate Affiliates Sponsors

Diamond ($80,000)Merck & Co., Inc.

Platinum ($10,000)Aventis PharmaceuticalsSchering

Gold ($5,000)Gyrus ENTKarl Storz Endoscopy-America

Silver ($2,500)Bayer PharmaceuticalsMedtronic-XomedOrtho-McNeil PharmaceuticalsRichard Wolf Medical Instr. Corp.

Bronze ($1,000)GE Medical Systems Navigation and VisualizationMuro PharmaceuticalsSteere PharmaceuticalsSinus Pharmacy

Friends of the Society ($500)BrainLab, Inc.

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2002 Committee Chairmen

Information Technology CommitteeMartin Citardi, MD

Newsletter CommitteeBrent Senior, MD

Program CommitteeJames Hadley, MD

Corporate Affiliate CommitteePaul Toffel, MD

ACCME CommitteeJames Stankiewicz, MD

Patient Advocate CommitteeMichael Sillers, MD

Research Grant CommitteeThomas McCaffrey, MD

Education CommitteeWinston Vaughan, MD

Membership CommitteeDaniel Becker, MD

Credentials CommitteePeter Hwang, MD

Awards CommitteeAllen Seiden, MD

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Upcoming Dates

August 1, 2003Deadline for Cottle Award Submission

September 20, 2003ARS Fall Meeting, The Peabody Hotel, Orlando, FL

October 3, 2003IRS/ISIAN, Seoul, South Korea

September 17–18, 2004ARS 50th Anniversary Fall Meeting,Hilton New York, New York, NY

April 30 – May 4, 2004COSM 2004, Desert Ridge, AZ

May 12–17, 2005COSM 2005, Boca Raton, FL

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Conference Schedule

May 2, 2002

1:00 pm

Welcome and Introductions

Donald Lanza, MDJames A. Hadley, MD

Pathophysiology of Disease

Moderators

Thomas Tami, MDScott Graham, MD

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1:05 pm

Expression of Cell Surface ImmuneMolecule Genes by Human Middle Meatal

Epithelial Cells in Culture

Andrew P. Lane, MDBahman Saatian, M.D

Xiao-Ying Yu, MDErnst Wm. Spannhake, PhD

Baltimore, MD

Introduction: Although the mechanisms underlying the initia-tion and maintenance of inflammation in chronic rhinosinusitisare poorly understood, the activation of memory T-cells withinthe nasal mucosa is thought to play an important role. T-cell acti-vation requires the presentation of antigen byimmunocompetent cells in the context of cell surface immunemolecules. The purpose of this study was to investigate the ex-pression of such molecules by human sinonasal epithelial cellsgrown in culture at the air-liquid interface (HLI).

Methods: Middle meatal epithelium was obtained from six pa-tients undergoing endoscopic sinus surgery. Dissociated epithe-lial cells were grown to confluence in serum-free, definedmedium and transferred to filter inserts for culture at the ALI.Cells were harvested at 2 and 21 days of growth at the ALI andprocessed for real-time PCR. The presence and relative abun-dance of constitutively expressed mRNA for HLA-B, B7H3,HLA-DR, B7H2, B7.2, and B7.1 were assessed.

Results: After 2 days at the ALI, middle meatal epithelial cellswere demonstrated to express genes for each of the cell surfaceimmune molecules tested. The expression of HLA-DR and B7.1increased significantly with longer growth at the ALI.

Conclusions: Primary human epithelial cells obtained from themiddle meatus express genes for cell surface immune molecules.The pattern of gene expression changes as the cells differentiateat the ALI. This finding suggests that mature middle meatal epi-thelial cells have the cellular machinery to interact with T-cellsand therefore may be direct participants in the activation ofT-cells in chronic rhinosinusitis.

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1:13 pm

Glycodelin — A Novel Immunomodulatoryand Proangiogenic Molecule in Chronic

Sinusitis

Ian Murton MDSam Parthasarathy PhD

John DelGaudio MDGiri Venkatraman MD

Atlanta, GA

Exposure to environmental allergens or a viral upper respiratoryinfection leads to inflammation and tissue edema in the mucosaof the nasal cavity and sinuses. This process in turn leads to ob-struction of mucosal outflow, and bacterial superinfections oracute bacterial sinusitis (ABS). Although the acute process is of-ten self-limiting, a subset of patients develops chronic inflamma-tion (CRS), and in extreme cases, forms benign inflammatorypolyps. Many previous studies have demonstrated increased ex-pression of pro-inflammatory cytokines in the nasal mucosa andin the nasal polyps in patients with CRS as well as allergic rhini-tis. However, the cascade of upstream cellular and molecularevents inducing this aberrant cytokine production in CRS is notwell understood. In addition, we can also presume thatangiogenesis and neo-vascularization are required for nasalpolyp formation although no direct evidence exists for this hy-pothesis. Here we describe the differential expression ofglycodelin, a novel protein, in both normal and CRS nasal mu-cosa. We also show that nude mice injected with glycodelin formnew blood vessels, and, in addition, allergen challenge leads toglycodelin production by lymphocyte precursor cells. Based onthis data, we propose that glycodelin plays a key role in both theimmune dysfunction and the angiogenesis that are the hall-marks of CRS and nasal polyps.

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1:20 pm

Human Defensins in Patients with ChronicRhinosinusitis with/without Cystic Fibrosis

Jivianne T. Lee, MDThomas C. Calcaterra, MD

Sunita Bhuta, MDThomas Ganz, MD

Los Angeles, CA

Introduction: Human alpha defensins 1-3 and beta defensin 2are members of a family of antimicrobial polypeptides that havebeen found to play a role in the host defense of the respiratorytract. The purpose of this study was to compare the expressionof human beta defensin 2 (HBD-2) and human neutrophil pep-tide (HNP) in patients with chronic rhinosinusitis (CRS)with/without cystic fibrosis (CF) to explore the hypothesis thatpatients with CF have increased inflammatory response com-pared to non-CF patients.

Methods: Specimens of sinus mucosa were collected from 11patients with CF who underwent endoscopic sinus surgery(ESS) for CRS. Similar specimens were obtained from 8 patientswithout CF who also underwent ESS for CRS. After tissue pro-cessing, immunohistochemical stains were performed to searchfor HBD-2 and HNP.

Results: Global staining for HBD-2 was positive in 9/11 CF pa-tients as opposed to 0/8 non-CF patients. Intraepithelial stainingfor HBD-2 was also evident in 5/11 CF patients in comparison to0/8 non-CF patients. With respect to HNP, global staining wasseen in 9/11 CF patients versus 0/8 non-CF patients.Intraepithelial staining for HNP was positive in 6/11 CF patientsbut only 1/8 non-CF patients. However, in the non-CF patients(8/8), scattered foci of HNP staining were seen within thesubepithelial stroma.

Conclusions: Patients with CRS and underlying CF expressHBD-2 and HNP to a greater degree than non-CF patients. Thisfinding supports the theory that CF patients with CRS have amore intense inflammatory response than non-CF patients withCRS and may contribute to the poorer clinical course often seenin the CF group.

1:28 pm

Discussion

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1:35 pm

The Role Interleukins and TGF-Beta inChronic Rhinosinusitis and Nasal Polyposis

Dewayne T. Bradley, MDStilianos E. Kountakis, MD, PhD

Charlottesville, VA

Objectives: To determine the role of, IL-4, IL-4 rececptor (IL-4R),IL-6, IL-8, IL-11 and TGF-Beta in chronic rhinosinusitis (CRS)and chronic rhinosinusitus with nasal polyposis (CRS/NP).

Methods: Sinus tissue from patients undergoing endoscopic si-nus surgery for CRS and CRS/NP was collected. Sinus tissuewas then analyzed using reverse transcription polymerase chainreaction (RT-PCR) to detect transcription of IL-4R, IL-6, IL-8,IL-11 . Sinus tissue samples were also cultured in-vitro, treatedwith IL-4 for 24 hrs and real time PCR used to quantitate thetranscription of TGF-Beta.

Results: Twenty patients were evaluated, 9 with CRS/NP and 11with CRS alone. The mean age was 43 (20-74) with 13 femalesand 7 males. IL-4R, IL-6, IL-8, IL-11 were identified by RT-PCRin all 20 patients. The transcription of TGF-Beta was found to be3.2 times greater in patients with CRS/NP than in patients withCRS alone, P=0.047.

Conclusions: IL-6, IL-8, and IL-11 are nonspecific markers of si-nus inflammation being transcribed in patients with CRS andpatients with CRS/NP. However, patients with CRS/NP demon-strate increased transcription of TGF-Beta in response to IL-4treatment, suggesting a IL-4 mediated mechanism for stromalproliferation in the formation of nasal polyposis.

Conflicts details: Stilianos Kountakis, MD, PhD — Speaker forSchering, GSK, Bayer, BMS, Merck; Research grants from BaxterMedical, Schering

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1:42 pm

Nitric Oxide Regulates Collagen Expressionin Allergic Upper Airway Disease

Marc A. Tewfik, MDSaul Frenkiel, MD

David H. Eidelman, MDJichuan Shan, MDMontreal, Canada

Background: The presence of nitric oxide (NO) in high concen-trations has been described in the nasal mucosa of patients withuntreated allergic rhinitis. We sought to examine the role of ex-ogenous, as well as endogenous, NO in the production of colla-gen type I and type III by human nasal fibroblasts.

Methods: Primary cultured fibroblasts derived from nasal pol-yps were exposed to NO-donors (SNAP 500 micromolar andDETA-NONOate 1000 micromolar), and various other com-pounds, over 24-hour incubation periods. Collagen productionwas evaluated qualitatively by immunocytochemistry, andquantitatively by western blot analysis.

Results: Maximally stimulated fibroblasts demonstrated a2.5-fold increase in the production of type III collagen relativetype I, as compared to baseline. Oxyhemoglobin, a NO scaven-ger, abolished this effect. Five-hundred micromolar SNAPcaused a 14% increase in collagen type I synthesis as comparedto unstimulated controls. Incubation with SNAP also caused anincrease in collagen type III production by a factor of 35%.

Conclusions: Nitric oxide stimulates collagen expression in hu-man nasal polyp-derived fibroblasts; this upregulation is prefer-ential to collagen type III, causing a shift in the ratio of collagentype I to type III production.

1:50 pm

Discussion

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Outcomes Management

Moderators

Joseph Jacobs, MDStilianos Kountakis, MD, PhD

2:00 pm

Objective Testing and Quality of LifeEvaluation in Chronic Rhinosinusitis

Timothy L. Smith, MD, MPHTodd A. Loehrl, MD

John S. Rhee, MDAnn B. Nattinger, MD, MPH

Milwaukee, WI

Objectives: Discordance has been reported between patientsymptoms and objective measures of disease in chronic sinusitis,such as radiographic evaluation. The objective of this study wasto evaluate the association between presurgical objective studiesand presurgical quality of life (QOL).

Study Design: Cross-sectional study of 90 consecutive patientspresenting to a tertiary rhinology practice for surgical manage-ment of sinonasal disease.

Methods: Quality of life assessment was performed utilizingdisease-specific instruments (Chronic Sinusitis Survey andRhinosinusitis Disability Index). Computed tomography scanswere scored according to the Lund-Mackay CT scoring systemand endoscopy evaluation scored by the system proposed byLund and Kennedy.

Results: Ninety surgical candidates were enrolled and includedin the analysis. Correlation between the QOL total scores andsubscale scores was excellent (r=0.39, p=0.0001) as was the corre-lation between CT and endoscopy scores (r=0.59, p=0.0001). Incontrast, correlation between QOL and objective measures wasnot significant (r=0.17, p=0.096). These results were not signifi-cantly influenced by subgroup analysis by diagnosis,comorbidity, and other patient factors.

Conclusions: Preoperative objective measures of CRS diseasedo not correlate with disease specific QOL measures in surgicalcandidates. It is likely that CT and endoscopy are measuring adifferent aspect of CRS disease than the QOL measures. It is alsopossible that preoperative QOL, either alone or in combinationwith CT and endoscopy, may prove important in selecting pa-tients most likely to benefit from surgery.

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2:08 pm

Outcomes of Endoscopic Rhinologic SurgicalProcedures Performed in the Office Setting

Joseph K Han, MDDan Bishop, BS

Karen J Fong, MDPeter H Hwang, MD

Portland, OR

Introduction: Endoscopic techniques have allowed a variety ofsinonasal surgical procedures to be performed in a minimally in-vasive manner. Many procedures that have traditionally beenperformed in the operating room may be well-suited to the of-fice setting. We review our experience in performing endoscopicsurgical procedures in an ambulatory clinic setting.

Methods: Retrospective chart review was performed on pa-tients who underwent endoscopic surgical procedures at the Or-egon Sinus Center clinic between 1997 to 2002. Basic proceduressuch as diagnostic nasal endoscopy, debridement, and control ofepistaxis were excluded. Anesthetic agents and complicationswere recorded, and a patient satisfaction telephone interviewwas conducted.

Results: 51 procedures were identified in 42 patients, with amean age of 50 years. Six patients had multiple procedures. Theprocedures consisted of 22 microdebrider polypectomies, 9 revi-sion maxillary antrostomies, 8 ethmoidectomies, 3sphenoidotomies, 3 frontal sinusotomies, 3 inferior turbinate re-ductions with outfracture, 2 marsupializations of a mucoceleand nasopharyngeal cyst, and 1 revision dacrocystorhinostomy.Eighty four percent of the patients were treated with a combina-tion of topical and injectable anesthetic. Estimated blood losswas 15 cc in all cases. There were no immediate or delayed com-plications at a mean follow up of 17 months. There was a highdegree of patient satisfaction, with over 90% of patients statingthat they would prefer the office setting over the operatingroom.

Conclusions: Selected endoscopic surgical procedures can beperformed in an ambulatory setting under local anesthesia withminimal morbidity and a high rate of patient satisfaction.

2:18 pm

Discussion

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2:25 pm

Long-Term Asthma Outcomes FollowingEndoscopic Sinus Surgery

Todd A. Loehrl, MDTimothy L. Smith, MD, MPH

Robinson M. Ferre BSRobert J. Toohill, MD

Milwaukee, WI

Objectives: Aspirin triad disease (ATD) is a well known clinicalentity characterized by asthma, polyposis, and aspirin intoler-ance. Using subjective and objective clinical data, this study ex-amines the short and long-term outcomes of asthma followingsinus surgery in patients with ATD.

Study Design: A retrospective review and standardized surveyin the setting of an academic tertiary referral center.

Methods: Sixty-five patients with ATD who had endoscopic si-nus surgery between 1986 and 1998 were identified from an in-ternal database. Surveys were utilized to assess objective andsubjective improvement of their asthma.

Results: Thirty-six of sixty-five patients with ATD who under-went endoscopic sinus surgery responded to the survey. Respon-dents had a mean follow-up of 10.0 years. Overall, 29 of 31patients (94%) who reported asthma symptoms preoperativelynoted postoperative improvement. Furthermore, 21 of these 31patients (68%) reported further improvement of their asthma be-yond the first postoperative year. Empergency department visitsfor asthma exacerbations decreased in 17 of 18 (94%). Inpatienthospitalizations for asthma exacerbations also decreased in thefirst postoperative year in 10 of 11 (91%)patients. Asthma attacksdeclined in 12 of 29(41%) patients the first year while continuedimprovement was noted by 13 of 29 patients (45%) beond thefirst year. Peak flow rates improved from an average of 60% ofthe predicted value pre-operatively to 86% at the time of fol-low-up.

Conclusions: The asthma component of ATD continues to im-prove with time follwoing endoscopic sinus surgery. While themost dramtic decrease occurs in the first year following sinussurgery, the majority of patients noted further improvement insubsequent years.

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2:35 pm

How Subjective Is Nasal Endoscopy? AStudy of Inter-Rater Agreement Using the

Lund & Mackay Scoring System

Haytham Kubba (*author for correspondence*), MDSivakumar Annamalai (*presenting author*), MD

Jeremy Davis, MDGlasgow, Scotland

Background: Scoring systems standardise the recording of nasalendoscopy findings. The extent to which two surgeons agree onthe findings of nasal endoscopy in adults is unknown, although astudy in children showed good agreement between two observers1. We wish to determine the inter-observer agreement of adult na-sal endoscopy scored with the Lund & Mackay system 2.

Methods: A consecutive series of rhinology clinic patients wasrecruited. All were examined with a zero degree 4mm endo-scope by two surgeons on the same clinic visit. Each independ-ently recorded their findings using the Lund & Mackay system,which rates polyp, oedema, discharge, crusting and adhesionseach on a scale of 0, 1 or 2. Neither surgeon was aware of theother’s findings.

Results: 30 patients were studied, 16 female, 14 male. Since theendoscopic findings were recorded separately for each side ofthe nose, each surgeon made 60 observations. Inter-rater agree-ment was calculated as Cohen’s kappa (1=perfect agreement,0=agreement expected by chance). The number of observationswith exact agreement was 59/60 for polyp (kappa=0.93), 43/60for oedema (kappa=0.45), 55/60 for discharge (kappa=0.84), and53/60 for crusting (kappa=0.62). Adhesions were only present inone patient.

Conclusions: Two independent observers agree on the findings ofnasal endoscopy in a high proportion of cases. Nasal endoscopy isreliable, especially when the Lund & Mackay system is used.

References:1. Kubba H, Bingham BJG. Endoscopy in the assessment of chil-dren with nasal obstruction. Journal of Laryngology andOtology 2001; 115: 380-384.

2. Lund V, MacKay I. Staging in rhinosinusitis. Rhinology 1993;31: 183-184.

2:42 pm

Discussion

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2:48 pm

Transnasal Endoscopic Surgery for Resectionof Angiofibroma with and without Arterial

Embolization

Mohammad Hossein Baradaranfar, MDFarhad Fatehi, MD

Yazd, Iran

Background: Juvenile nasopharyngeal angiofibroma (JNA) is arare benign but aggressive tumor of head and neck.

Many surgical procedures have been described for resection ofthis tumor but endoscopic surgery in recent years hasrevoloutionized its treatment. This method is usually used afterarterial embolization.

Materials and Methods: 16 patients with mean age of 16.5yearswere treated with endoscopic approach between march 1997 toJune 2000. Patients were in stages IA to lIB based on Sessionclassification.

In 3 patients preoperative emblizarion were not performed. Ofcases, 14 patients were treated for the first time and 2 cases forrecurrence after external approaches.

All cases were investigated with CT and/or MR1 and carotidangiography preoperatively and with CTor MR1 and periodicendoscopy after operation.

Operation Technique: Under general anesthesia with controlledhypotension, the tumor was slowly pulled down with applica-tion of a retractor to expose sphenopalatine foramen. Then thetumor pulled out of foramen by a seeker.After detachment of tu-mor form nasal mucosa and sphenoid sinus, it pushed mediallyand inferiorly. If there was extension to lower part of pterygo-maxillary fossa or to infratrmporal fossa, inferior part of inferiorturbinate was resecred or it pushed inferoposteriorly. Tumor isthan grasped and pushed medially to expose its origin. Afterremoval of posterior wall of maxillary sinus and elevation ofretromaxillary periosteum, the infratemporal fossa will be acces-sible.After clipping the maxillary artery; the tumor will bepulled out of nostril.

Results: Mean follow-up time was 44-1 months. No case of recur-rent disease or major complication were seen. The amount of bloodloss or need for transfusion were comparable with other series.

Conclusions: Endoscopic surgery is a safe and reliable methodfor JNA treatment with results that are comparable with openapproaches.Preoperative embolization is not an obligatory com-ponent of endoscopic approach. In conclusion the endoscopicapproach is an acceptable alternative in small to middle sizedJNA.

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2:55 pm

Discussion

3:00 pm – 3:30 pm

Break with Exhibitors

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Surgical Techniques

Moderators

Steven Marks, MDJames Stankiewicz, MD

3:30 pm

Management of Late Sequelae of theCaldwell Luc Procedures

Joseph K Han, MDTimothy L Smith, MD, MPH

Todd A Loehrl, MDPeter H Hwang, MD

Portland, OR

Introduction: Prior to the introduction of endoscopic sinus sur-gery, the Caldwell Luc (CL) procedure was the traditional surgi-cal management for medically refractory maxillary sinusitis. Asendoscopic surgeons, we are commonly faced with the manage-ment of patients who have persistent maxillary sinusitis in theface of previous Caldwell Luc surgery. The objective of this pa-per was to review long-term outcomes and management of pa-tients who have undergone a CL for chronic maxillary sinusitis.

Methods: Retrospective chart review was performed on pa-tients who underwent a CL procedure for chronic sinusitis at theOregon Health & Science University and Medical College ofWisconsin between 1965 and 2002.

Results: One hundred and seven patients were identified with amean follow up period of 85 months. A total of 174 CL proce-dures were performed and fifty percent of the maxillary sinusesrequired revision surgery. Of the patients who underwent addi-tional procedures, 61% were managed endoscopically with anaverage of 1.7 additional procedures and 39% were managedwith another CL procedure with an average of 1.3 additionalprocedures. Six percent of patients developed a maxillarymucocele at a mean follow up period of 90 months from the firstCL procedure.

Conclusions: Patients who have undergone a Caldwell Luc pro-cedure are likely to require surgical revision. Despite a history ofmucosal stripping of the maxillary sinus, many patients may besuccessfully revised through endoscopic approaches. Patientswho have a history of CL surgery should be followed carefullyfor late complications of maxillary sinus mucoceles.

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3:38 pm

Endoscopic Modified Lothrop Procedure:Indications and Results of

Short-term Stenting

William O. Collins, MDSarita Kaza, MD

Roy R. Casiano, MDMiami, FL

Introduction: Despite significant improvement in symptoms,restenosis (2% intraoperative size) of the common frontalostium, after an endoscopic modified Lothrop Procedure, stilloccurs in a significant number of patients. Historical or clinicalfactors contributing to the rate of restenosis, and recurrence ofsymptoms, are not clearly defined. Also, the efficacy of stenting,with silastic sheeting, in reducing the incidence of restenosis isnot well reported.

Methods: A retrospective review of 41 patients who underwentan endoscopic modified Lothrop Procedure was conducted. Pa-tients were divided into three groups based on their main indi-cation for surgery: neoplasm exposure and resection, chronicrhinosinusitis with nasal polyps, and chronic rhinosinusitiswithout polyps. A variety of preoperative, intraoperative, andpostoperative factors (i.e., ostium size, presence ofosteoneogenesis or fibrosis, and use of stenting) were correlatedwith the incidence of restenosis and improvement of symptoms.

Results: The patency rate for patients undergoing surgery forneoplasm versus chronic rhinosinusitis was 86% versus 57%.Patency rates did not differ between polyp and non-polypformers. Few patients had complete closure of the ostium (7%).Despite restenosis, a significant number of patients had im-provement in symptoms. A direct correlation between improve-ment in headaches, infections, and nasal obstruction, and frontalostium patency was observed. Stented patients with chronicrhinosinusitis showed an overall improvement in ostiumpatency (67%), with more dramatic improvements in headacherelief (75% vs. 60%), decreased infections (100% vs. 67%), andnasal obstruction (100% vs. 100%), as compared to non-stentedpatients.

Conclusions: The endoscopic Lothrop procedure provides areasonable alternative to historically more extensive frontal si-nus surgeries, and provides good symptomatic relief. In selectpatients, with more extensive inflammatory disease necessitat-ing more extensive bony resection or exenteration of mucosa,short-term stenting, may improve ostium patency.

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3:46 pm

Endoscopic Management of Failed FrontalSinus Obliteration

James N. Palmer, MDRakesh K. Chandra, MDDavid W. Kennedy, MD

Philadelphia, PA

Background: Frontal sinus obliteration (FSO) has traditionallyrepresented the final stage in the algorithm for difficult to man-age frontal sinus disease. FSO has also been employed in se-lected cases of frontal sinus trauma. This procedure, however,has been associated with failure in approximately 5% of cases.Advances in surgical instrumentation and stereotactic naviga-tional technology have permitted endoscopic management ofthese failures.

Methods: Ten patients presenting with failure of a previouslyperformed FSO were managed endoscopically with the assis-tance of stereotactic imaging.

Results: Initial frontal sinus pathology included chronic inflam-matory disease in 6 patients and frontal sinus trauma in 2 pa-tients. Two patients underwent obliteration followingneurosurgical frontal craniotomy. Frontal sinuses were obliter-ated with fat in 7 cases, bone chips in 2 cases, and bone cementin 1 case. The mean time interval to FSO failure was 10.5 years(range 4 months - 35 years). The etiology of failure includedmucocele in 7 patients, chronic frontal sinusitis in 2 patients, andPott’s puffy tumor in 1 patient. All patients underwent endo-scopic frontal sinusotomy, of which 2 were by a trans-septal ap-proach. A drill was utilized for frontal sinusotomy in 3 cases. Inone additional patient, trephination was performed in conjunc-tion with the endoscopic sinusotomy. Two patients required re-vision endoscopic surgery, but all sinusotomies are patent in theearly follow-up period (mean = 11.3 months).

Conclusions: Endoscopic management of failed FSO may beperformed safely. These approaches are viable alternatives toopen revision procedures in the management of failed FSO.

3:54 pm

Discussion

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4:00 pm

Endoscopic Management of ExtensiveSinonasal Inverted Papilloma

Mark Jameson, MD, PhDStilianos Kountakis, MD, PhD

Charlottesville, VA

Introduction: Given the malignant potential and propensity forrecurrence of inverted papilloma (IP) of the nasal cavity, com-plete excision is warranted. However, the morbidity of open sur-gical procedures is high and control of recurrence is difficult.The more conservative endoscopic approach provides excellentvisualization, permits removal of diseased mucosa while pre-serving vital anatomic structures, and allows for excellentpost-operative surveillance. Recurrences are identified early andendoscopic re-resection is repeated as necessary until there is noevidence of disease.

Methods: Data was prospectively collected and subsequentlyreviewed on 13 patients who underwent endoscopic manage-ment of extensive IP (present at more than one anatomic site) be-tween 1999 and 2002.

Results: Ten males and 3 females ages 36-74 (average 51) werefollowed for an average of 17 months (range 6-36 months) afterinitial endoscopic resection. Patients all complained of nasal air-way obstruction for 6 months to 1 year and had undergone anaverage of 1.2 procedures (range 0-3) prior to referral. The mostcommon sites affected were maxillary sinus, orbital floor, laminapapyracea, and ethmoid roof/cribiform plate. Patients requiredan average of 1.8 endoscopic surgeries (range 1-4) to achieve lo-cal control; 6 patients (46%) required only one. All patients weresymptomatically improved and complications were limited toone CSF leak, which was repaired intraoperatively. Conclusion:Extensive IP can be well-controlled using minimally invasive en-doscopic procedures as long as close follow-up is maintained.Operative risk and post-operative morbidity are significantlyless than observed with open procedures.


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4:08 pm

Endoscopic Closure of the Eustachian Tube

Richard R. Orlandi, MD, FACSClough Shelton, MD, FACS

Salt Lake City, UT

Introduction: Eustachian tube closure is occasionally indicatedfor conditions ranging from patulous Eustachian tube tocerebrospinal fluid leak. The authors demonstrate an endoscopicminimally invasive technique for successful closure of the Eusta-chian tube.

Methods: This is a description of a new technique that has beenemployed successfully in three patients. Two patients hadcerebrospinal fluid leakage down the Eustachian tube and men-ingitis following middle fossa skull base surgery. One patienthad autophony due to a patulous Eustachian tube accompany-ing weight loss.

Results: Follow up data demonstrate successful resolution ofthe cerebrospinal fluid rhinorrhea in both patients and improve-ment in the autophony in the remaining patient.

Summary: The demonstrated technique is a minimally invasivemethod of treating Eustachian tube patency problems in selectedpatients.

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4:16 pm

Management of the “Lateral Frontal SinusLesion:” The Supraorbital Mucocele

Alexander G Chiu, MDWinston C Vaughan, MD

Stanford, CA

Introduction: Masses that appear in the lateral aspect of thefrontal sinus can be difficult to access and are often approachedthrough external approaches. Supraorbital ethmoid cellspneumatize the orbital plate of the ethmoid bone to lie posteriorand lateral to the frontal sinus. Obstruction may result in asupraorbital cell mucocele, which radiographically gives the ap-pearance of a laterally based frontal sinus lesion. Knowledge ofthis anatomy allows surgical drainage to be achieved throughendoscopic techniques, and may obviate the need for an externalapproach.

Methods: Retrospective review of patients treated for asupraorbital cell mucocele at a tertiary sinus center was per-formed. Radiology, endoscopic findings and symptom outcomemeasures were reviewed.

Results: Ten patients were identified with supraorbital cellmucoceles based on 1 mm cut CT scans of the paranasal sinuses.Each patient underwent surgical drainage using computer-aidedendoscopic techniques. Drainage of the mucocele was successfulin each patient and without the need for an external incision.Each patient remains clear of disease at follow-up (range 8 - 38months) by nasal endoscopy and post-operative CT scans.

Conclusions: Knowledge of the anatomy of the supraorbital celland its relation to the frontal sinus recess, are important inachieving success through endoscopic means. Given the natureof mucoceles, long-term follow-up is needed before endoscopicdrainage of supraorbital mucoceles is validated. However, thispreliminary data suggests that an endoscopic approach to theselaterally based mucoceles provides adequate drainage andavoids an external incision.

4:22 pm

Discussion

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Review of Data

Moderators

Allen Seiden, MDEugenia Vining, MD

4:25 pm

A 15-Year Review of Invasive Fungal Sinusitis

John M. DelGaudio, MDShatul Parikh

Giridhar Venkatraman, MDAtlanta, GA

Objectives: Invasive fungal sinusitis (IFS) affects immuno-compromised patients with reported mortality rates of 50% to 80%.We reviewed our experience with patients with IFS to determineoutcomes and identify factors that may affect patient survival.

Methods: A retrospective review was performed between 1987and 2002. 39 patients were identified accounting for 41 cases ofIFS. Patients were included if they had a definitive diagnosis ofIFS based on pathology report confirming tissue invasion byfungus and/ or positive fungal cultures.

Results: The underlying reasons for immunosuppression werehematologic malignancy (HM) (26), diabetes mellitus (9), solidorgan transplant (3), chronic steroid use (2), and Acquired Im-munodeficiency Syndrome (1). Six of 41 cases (14.6%) died of IFSand 4 of 41 (9.8%) died of other underlying disease related com-plications with persistent IFS. Thirty-eight (93%) had one ormore surgical procedures for IFS (average 1.8 per patient). Allbut one patient received systemic antifungal therapy.

Of the twenty-six cases associated with HM, 3 died of IFS(11.5%), and 4 (15.4%) died of other causes with persistent IFS.25 (96%) had absolute neutrophil counts (ANC) of less than 500when symptoms began, and in the 3 deaths the ANC remainedat 0. 3 of 9 (33%) patients with DM died of IFS. Permanent mor-bidity related to IFS was also more common in DM patients.

Conclusions: In this series we have found the overall mortalityrate directly related to IFS to be 14.6%. The rate is higher for dia-betic patients than for patients with hematologic causes for theirimmunosuppression. This is likely due to the high suspicion andearly diagnosis and treatment of patients with neutropenia. Whilesurgical debridement, antifungal therapy, and granulocyte replen-ishment are important, these mainly serve to reduce fungal loadand augment neutrophil counts until the patient has a chance toregain natural immune function.

24

4:33 pm

Role of Nasal Endoscopy in PatientsUndergoing Endoscopic Sinus Surgery

Brian A. Kaplan, MDStilianos E. Kountakis, MD, PhD

Charlottesville, VA

Introduction: Determine the role of nasal endoscopy in patientsundergoing endoscopic sinus surgery. Examine the correlationbetween nasal endoscopy and pre and postoperative CT grade,symptom scores, and asthma status.

Methods: A prospective analysis was performed of patients pre-senting to a tertiary care rhinology practice for endoscopic sinussurgery from 1999-2002. Two hundred fifty-four consecutive pa-tients were analyzed, 131 males and 123 females, with a meanage of 48 years. All patients had a minimum of one year followup. All patients received preoperative CT scans and completedsymptom scoring, SNOT-20 questionnaires, and endoscopic ex-amination at both the preoperative and one year postoperativevisits. Correlation between the endoscopic grade and CT, symp-tom, and SNOT-20 findings was calculated. The role of asthmawas also calculated for the correlation between endoscopy andsymptom scores.

Results: Nasal endoscopy demonstrated a statistically signifi-cant correlation with preoperative CT grade in this patient pop-ulation. There was no correlation between endoscopic findingsand symptom scores. Patients with asthma (n=47) showed nosignificant correlation between endoscopic grade and either CTor symptom scores. Non-asthmatics (n=207) also correlated na-sal endoscopy with CT grade, but not with symptom scores.

Conclusions: Nasal endoscopic scoring does correlate with CTgrade in a non-asthmatic population. No correlation was foundbetween endoscopy and CT or symptom scores in patients withasthma.


25

4:41 pm

The Incidence of Sphenoid Sinus MucoceleFollowing Transsphenoidal Surgery: A Ten

Year Experience

Tarika Bhuta, MDChristopher R. Rassekh, MD

Jeffery P. Hogg, MDHassan R. Ramadan, MD

Morgantown, WV

Objectives: Scattered case reports of sphenoid sinus mucocelefollowing transsphenoidal surgery exist in the current literature,but the incidence is unknown. The purpose of this study is todetermine the incidence of mucocele formation in a large seriesof patients having undergone transsphenoidal surgery.

Methods: A retrospective review of charts of all patients under-going transsphenoidal surgery at our institution since 1992 wasconducted. Fifty patients were identified, with sixteen patientslost to follow up. Thirty-four patients’ charts and post-operativemagnetic resonance imaging (MRI) studies were reviewed toidentify the incidence of sphenoid mucocele formation. Surgicalprocedure was uniform in all cases with the sphenoid sinuspacked with fat. For the purpose of this study, all follow-upMRI’s were reviewed again by a neuroradiologist with attentiongiven to the sphenoid sinus.

Results: Thirty four patients were included in the study. Followup range was 3 to 107 months, with a mean follow up time of 46months. Three of thirty-four patients (9%) developed apost-operative sphenoid sinus mucocele based on imaging find-ings. None have required surgical intervention thus far.

Conclusions: The transsphenoidal approach for treatment ofintrasellar tumors has been widely used since the 1980’s becauseof its associated low morbidity and mortality. Our review showsthat sphenoid sinus mucocele development is a rare but typicalcomplication of sinonasal surgery often occurring several yearsafter the primary surgery. Therefore, it is necessary to be awareof the incidence of mucocele formation as a long term complica-tion of transsphenoidal surgery.

4:50 pm

Discussion

26

5:00 pm

Business Meeting ofthe American Rhinologic Society

Remarks By The Presidentand Committee Reports

5:30 pm

Adjourn

27

Saturday, May 3, 2003

8:00 am

Opening Remarks

Introduction of Audience Response System

28

Medical Management of ChronicRhinosinusitis

Moderators

Peter Hwang, MDRichard Orlandi, MD

8:05 am

Medical Management and Diagnosis ofChronic Sinusitis: US Treatment Patterns

Scott M. Kaszuba, MDMichael G. Stewart, MD, MPH, FACS

Houston, Texas

Introduction: This study was performed to identify current pat-terns of diagnostic criteria and medical treatment for chronic si-nusitis by otolaryngologists in the United States.

Methods: A 15-item survey was mailed to a random sample of200 members of the American Academy of Otolaryngol-ogy-Head and Neck Surgery; statistical analysis was performed.

Results: The overall response rate was 40.0%. Of respondents,73% defined chronic sinusitis (CS) as sinusitis lasting greaterthan 12 weeks. 73% also believed radiological imaging was nec-essary for definitive diagnosis, but only 30% believed nasal en-doscopy was necessary. Regarding treatment, respondentsreported use of oral antibiotics (94%) and nasal corticosteroids(94%) as part of maximum medical management; oral deconges-tants, oral mucoevacuants and allergy testing were only used byabout half of respondents, and used less frequently were topicaldecongestants (38%), oral corticosteroids (36%) and oral antihis-tamines (27%). Oral corticosteroids were more likely to be usedby specialists that self-classified as rhinologists than by otherotolaryngologists (p=0.005), but rhinologists were less likely useto radiological imaging (p=0.04) as a diagnostic criteria. Pediat-ric otolaryngologists used allergy testing in medical manage-ment more frequently than other otolaryngologists (p.001).Overall, the basis for choice of maximal medical managementwas personal clinical experience (74%), rather than clinical re-search results, or expert recommendations.

Conclusions: US otolaryngologists agree on the use of oral antibi-otics and nasal corticosteroids as part of maximal medical man-agement for chronic sinusitis, but do not agree on other adjuvanttherapies, or on the use of endoscopy as a diagnostic criteria.

29

8:12 am

Community Surveillance of Acute andChronic Rhinosinusitis

Farhan Taghizadeh, MDJames A. Hadley, MD, FACS

Rochester, NY

We initiated a prospective study of 174 patients presenting withrhinosinusitis to continue community surveillance of the mostcommon disease pathogens. 146 patients were evaluated foracute rhinosinusitis, with 36 patients under age 18. 28 adult pa-tients presented with chronic rhinosinusitis. All patients greaterthan age 15 had endoscopic directed cultures, all children wereswabbed nasally. All patients were evaluated at a single outpa-tient facility. For the adult acute bacterial rhinosinusitis group,H. Influenzae (24%), Strep. Pneumoniae (21%), StaphAureus(18%), and M. Cattarrhalis (17%) were primarily cul-tured. For the pediatric acute bacterial rhinosinusitis group, H.Influenzae (25%), Strep. Pneumoniae (31%), Staph Aureus(17%),and M. Cattarrhalis (19%) were primarily cultured. Only 10 sam-ples grew more than one dominant primary organism. ChiSquare analysis showed no difference in the frequency of thesemajor organisms between the pediatric and adult acuterhinosinusitis groups. This data was compared to previouslypublished community surveillance data, showing similar resultsexcept for the much higher frequency of Staph. Aureus culturefrequency. For the chronic rhinosinusitis group, H. Influenzae(11%), Strep. Pneumoniae (4%), Staph Aureus (43%), and M.Cattarrhalis (4%), Psudomonas (25%) were primarily cultured.Again, we note the increasing frequency of Staph Aureus in thispopulation compared to our previously published data. Ourfindings emphasize the rapidly changing patterns of bacterialprevalence for acute and chronic rhinosinusitis.

8:20 am

Discussion/Audience Response Questions

30

8:28 am

Correlations Between SPECT Bone Scanningand Histopathology of the Ethmoid

Bulla-Part I

Peter J. Catalano, MDRobert W. Dolan, MD

John H. Romanow, MDMark L. Silverman, MD

Burlington, MA

Introduction: Recent reports in the rhinology literature suggestthat osteitis of the ethmoid bone may be responsible for refrac-tory and/or recurrent sinusitis. Although this theory remainscontroversial, it suggests new treatment paradigms may be nec-essary for patients with chronic sinusitis and bone scanningtechnologies may be useful in diagnosing this condition and itsresponse to treatment.

Methods: 38 patients diagnosed with chronic sinusitis andscheduled to undergo sinus surgery underwent a pre-surgicalSPECT bone scan using technetium 99M-MDP. All bone scanswere done within 5 days of surgery. During the procedure, bonesamples from the face of the ethmoidal bulla were obtained bi-laterally and examined by a pathologist blinded to the bone scanresult. Surgeons were also blinded to the bone scan and pathol-ogy results. In this study, histopathology consistent with osteitiswas defined as a change from lamellar to woven bone. A bonescan was defined as positive if increased radiotracer uptake waspresent in the ethmoid sinuses.

Results: 32 patients had a positive bone scan on SPECT imag-ing. Of these 32 patients, histopathologic bone changes consis-tent with osteitis were found in 31 specimens and absent in one.An additional 6 patients had a negative bone scan on SPECT im-aging. Histopathology was unremarkable in 5/6; osteitis wasidentified in 1/6.

Conclusions: SPECT bone scanning with technetium 99M-MDPmay be a reliable means to identify those patients with chronicsinusitis more likely to benefit from surgical intervention.

31

8:36 am

MR Findings of Inverted Papilloma:Differential Diagnosis with Malignant

Sinonasal Tumors

Roberto Maroldi, MDLaura Palvarini, MD

Davide Lombardi, MDPiero Nicolai, MD

Brescia, Italy

Purpose: To evaluate the MR pattern of inverted papilloma (IP)and differentiate it from sinonasal malignant tumors (MT).

Patients and Methods: MR examinations of 23 patients affectedby IP (16 primary, 7 recurrent) and 23 patients affected by MT(12 adenocarcinomas, 9 squamous cell carcinomas, 2neuroendocrine carcinomas) were evaluated. The IPs arose fromthe lateral nasal wall in 17 cases, from the maxillary sinus in 5cases, and from the nasal septum in one patient. The signal in-tensity of IP and MT was compared to muscles on SET2 andSET1 images; contrast enhancement was compared to nasal sep-tum mucosa. Bone involvement was graduated as remodeling orerosion (focal mm; intermediate; extended 30mm). Correlationbetween bone changes and size or histology of the lesions wasstudied by Pearson’s test.

Results: The average size of the IPs was significantly less thanthat of MT (33.9 mm vs. 59 mm, P=0.0003). IP showed a colum-nar pattern in all 23 cases by enhanced SET1 images and in 16 of23 lesions (20mm diameter) by SET2. This pattern was observedin only 1 of the 23 MT: pathologic examination of that specimendemonstrated multiple foci of IP associated with SCC. Bone re-modeling was observed in 19 of 23 IP, which in 4 cases was asso-ciated with focal (2) or intermediate (2) erosion. Bone changesdid not correlate with size of IP. In all MT remodeling was pres-ent, combined with focal (2/23) or extended (21/23) erosion. Astrong correlation was found between pattern of bone changesand histology (r=0.89).

Conclusions: Columnar pattern is a reliable MR sign of IP andreflects its histological architecture (positive predictive value95.8%). The combination of this finding with the absence of ex-tended bone erosion allows for the confident discrimination ofIP from MT.

32

8:42 am

Quantitative Computer-Aided CT Analysisof Sphenoid Sinus Anatomical Relationships

Ryan P. Gallivan, MDDonald C. Lanza, MD

Calvin R. Maurer, Jr., PhDMartin J. Citardi, MD

Bend, OR

Introduction: A central tenet of safe sphenoid surgery is theavoidance of lateral manipulations within the sphenoid sinus.This CT-based study utilizes a novel computer-generated ana-tomical symmetry plane as a framework for the quantitative de-scription of the anatomy of the sphenoid sinus and adjacentstructures.

Objectives: To determine relationships and distances between amidline reference point within the sphenoid sinus and lateralsphenoid wall landmarks and structures.

Materials and Methods: Axial CT scans (1 mm slice thickness)were obtained on a VolumeZoom CT scanner (Siemens Medical,Erlangen, Germany). Mathematically derived anatomical sym-metry planes were created using custom post-processing soft-ware. CT image data sets were transferred to the CBYON DoctorStation version 2.6R3FC4 (CBYON, Inc., Mountain View, CA).Standardized review of each CT scan using various surgicalplanning tools was performed. The central sphenoid point (CSP)was defined as the reference point in the midline sagittal planeat the intersection of the vertical sellar face and the horizontalsellar floor.

Results: A total of 128 sides in 64 cadaveric specimens wereavailable for review. The incidences of anterior clinoid process(ACP) pneumatization and lateral pterygoid recess (LPR)pneumatization were 23.4% and 37.5%. The mean distance be-tween the CSP and the maxillary spine (MS) was 76.4 mm. Themean distances from the CSP to the left optic canal midpoint(OCMP), the left anterior clinoid process entrance point(ACPEP) and the left lateral pterygoid recess lateral wall(LPRLW) were 17.2, 15.6, and 27.6 mm, respectively. The corre-sponding distances from the CSP on the right side were 17.3,15.8, and 28.0 mm, respectively. The distances from MS toOCMP, ACPEP and LPRLW were 71.9, 75.3, and 72.0 mm on theleft side. The corresponding distances from MS on the right sidewere 72.0, 75.0, and 72.0 mm, respectively.

Conclusions: This approach provides both quantitative under-standing of sphenoid osteology, and may be coupled withintraoperative surgical navigation to reduce the risks ofsphenoid surgery. LPR pneumatization is surprisingly common,and may provide a route for transnasal endoscopic procedures

33

of the middle cranial fossa skull base. ACP pneumatization ex-poses the optic nerve to the risk of inadvertent injury and createsa path for surgical decompression of the optic nerve. Because theCSP-derived relationships may be referenced during endoscopicsurgical navigation from within the operative site, it may pro-vide greater clinical utility than traditional references from themaxillary spine. This paradigm may facilitate greater under-standing of sphenoid anatomy and enhance surgical safety andprecision.

Conflict Details: Calvin R. Maurer, Jr., PhD — Grant/ResearchSupport from CBYON, Inc.; Consultant for CBYON, Inc.; Mem-ber of the Scientific Advisory Board of Advanced Imaging Tech-nologies, Inc. (AIT).

8:50 am


Moderator

William Bolger, MD

34

Rhinosinusitis and the Laboratory

9:00 am

Is Bone Infection a Reason for ChronicSuppurative Rhinosinusitis?

Sara L. Retsema, MDJoseph P. Allegretti, MD

Neal M. Lofchy, MDWilliam R. Panje, MD

Chicago, IL

Introduction: Experimental data from previoushistomorphometric studies of chronic suppurative rhinosinusitis(CRS) have reported changes in underlying bone suggestive ofosteomyelitis. This inflammatory and infectious process in thebone may be a significant factor in the persistence of CRS andnecessitate biopsy for culture directed antibiotic treatment. Thepurpose of this study is to evaluate ethmoid and maxillary bonein CRS for osteomyelitis based on bone culture and pathology.

Methods: A prospective study of 10 adult patients treated withfunctional endoscopic sinus surgery for CRS was completed. Tis-sue and underlying bone samples from diseased sinuses wereobtained and sent separately for aerobic, anaerobic, and fungalculture. An additional sample of diseased sinus was stained byhematoxylin and eosin and analyzed for pathology.

Results: Bacteria was positively cultured from 90% of bone iso-lates. Bacteria in the sinus mucosa was generally representativeof the organisms in the underlying bone. Pathological examina-tion revealed chronic inflammation in all cases with a predomi-nance of membranous inflammation.

Conclusions: The positive bacterial bone cultures support infec-tion in bone as a major contributor to the pathogenesis of CRS.The similarity of CRS to osteomyelitis may account for diseasechronicity and have further implications for the medical man-agement of CRS.

35

9:08 am

Allergic Fungal Sinusitis: Developing anAnimal Model

Felicia Johnson, MDJohn Houck, MD

Elizabeth Gilles, MDBlaine Smith, PhD.

Nashville, TN

Introduction: Allergic fungal sinusitis (AFS) is a chronicnoninvasive form of fungal sinusitits with an unclearpathogenesis and a high rate of recidivism. There has been sig-nificant controversy as to whether AFS represents a hypersensi-tivity to the fungi in a predisposed patient or an actual infectiousprocess. The histopathology of AFS has been shown to be identi-cal to that of allergic bronchopulmonary aspergillosis (ABPA),which led to the idea that the pathogenesis in the two diseases isthe same. It has long been known that both IgG and IgE antibod-ies specific to the causative fungal antigens are present in ABPA.However, the question of immunologic pathogenesis has notbeen clearly answered in AFS and there is no established animalmodel.

Objectives: The main objective of this study was to develop ananimal model for AFS. In addition, we hoped to gain informationregarding the possible immunologic pathogenesis behind the dis-ease and the roles of IgG and IgE fungal-specific antibodies.

Methods: A pilot study was first performed to determine theoptimal dose of Aspergillus fumigatus antigen forimmunosensitization of New Zealand white rabbits. Once thiswas determined, the rabbits (n=8) were then actively immunizedusing fungal antigen combined with complete Freund’sadjuvant and then given a booster 3 weeks later. Control rabbits(n=4) were not actively immunized and baseline IgG and IgEtiters were obtained. Post-immunization fungal-specific IgGtiters were measured with indirect ELISA testing. Fungal-specific IgE titers were measured by the homologous passive cu-taneous anaphylaxis (PCA). The rabbits were then challengedwith Aspergillus fumigatus spores by a percutaneous injectioninto each maxillary sinus. The rabbits were then observed overweeks to months, euthanized and tissue from the maxillary si-nuses harvested and stained with hematoxylin/eosin and GMSstains and evaluated by our staff pathologist.

Results: The optimal dose of Aspergillus fumigatus antigen forimmunization was determined to be 1 mg. We determined thatthe rabbit could indeed be sensitized to Aspergillus antigen andthat there was variability in antibody response between the vari-ous rabbits. Some of the rabbits mounted both an IgG and IgEresponse while others produced only IgG or were completenonresponders. Histopathology results showed focal areas of

36

acute and chronic sinusitis with allergic mucin present in severalof the specimens. This type of histologic response was not seenin the control group. GMS staining did not show any evidenceof fungal hyphae.

Conclusions: This study demonstrates that the rabbit can besensitized to the Aspergillus fumigatus antigen to produce bothIgG and IgE antibodies. Second, the control rabbits demon-strated no histologic evidence of sinusitis or any reaction to thefungal challenge which may suggest a possible immunologicpathogenesis behind AFS. The histologic results showed focalareas of acute and chronic sinusitis with allergic mucin whichmay represent AFS. With a few modifications of this model in re-gards to fungal inoculation methods as well as immunizationtechniques, this study may serve as a reliable animal model forAFS in the future.

9:16 am


37

New Etiologies??

Moderators

Andrew Lane, MDB.J. Ferguson, MD

9:20 am

A Superantigen Hypothesis for thePathogenesis of Chronic Hypertrophic

Rhino-Sinusitis

Joel M. Bernstein, MD, PhDGetzville, NY

Objective: To propose a theory and supporting data that mayaccount for the chronic inflammatory infiltrate in massive nasalpolyposis

Methods: 9 Patients with Chronic Hypertrophic Rhino-sinusitiswith massive nasal polyposis were studied. Nasal Washingswere submitted for bacteriological and fungal identification. Thehistopathology of the nasal polyps were studied in a semi-quantitative fashion. Only nasal mucus isolates with S. aureus,Coag. neg. Staph.and B-hem. Strep. were analyzed forenterotoxins ( superantigen). The Beta Variable region of the TCell Receptor (TCR) was studied in those patients in whichenterotoxins were isolated.

Results: 5 of 9 patients grews out Staph. aureus that producedenterotoxins. Enterotoxin A in 2 Patients and TSS-1 (Toxic ShockSyndrome-1 toxin)

in 3 patients. The T cells receptors included those that can bindmicrobial superantigens. No fungal elements were seen in thenasal washings. The histopthology of the nasal polyps consistedprimarily of lymphocytes, eosinophiles and plasma cells.

Conclusions: The pathogenesis of the chronic inflammation innasal polyposis consisting of heavy infiltration of lympho-cytes/eosinophiles may be the result of superantigen disease inwhich Staph. aureus releases enterotoxins (superantigens) whichstimulate the appropriate TCR V beta regions on lymphoctes.This interaction may result in a massive upregulation of lym-phocytes accounting for the chronic inflammatory disease seenin nasal polyposis.

38

9:35 am

Chronic Sinusitis with Polyps: Presence ofIgE to Staphylococcal Enterotoxins

David B. Conley, MDAnju Tripathi, MD

Megan M. Lowery, MDKristin A. Seiberling, MD

Chicago, IL

Rationale: Chronic sinusitis with polyps is a multifactorial dis-order often associated with the presence of bacteria, notablyStaphylococcus aureus, within the inflamed paranasal sinuses.IgE mediated hypersensitivity to Staphylococcal enterotoxinsmay be responsible for contributing to this chronic inflammationin certain patients. IgE to Staphylococcus enterotoxins has beendemonstrated in several studies of atopic dermatitis, wherethere is a similar colonization by Staphylococcus of the affectedskin. In addition, enterotoxins may act as superantigens, stimu-lating lymphokine release from T-cells.

Methods: Serum was drawn from 11 patients with sinonasalpolyps undergoing endoscopic sinus surgery as well as 13 atopicand non-atopic control subjects without sinusitis. IgE to Staphaureus enterotoxin B (SEB) and toxic shock syndrome toxin -1(TSST-1) was measured by ELISA. We compared degree of tissueinflammation in patients with IgE against staph enterotoxins tothose without IgE against Staph enterotoxins. Numbers of tissueeosinophils and lymphocytes on H&E stained sections of polypswere scored by a blinded pathologist.

Results: Serum levels of IgE to SEB or TSST-1 were positive in 6/11(55%) of patients with sinonasal polyps and 0/13 (0%) of controlsubjects. Patients with IgE against Staph enterotoxins tended tohave a greater intensity of eosinophils and lymphocytes in their tis-sue specimens as compared patients without the antibodies.

Conclusion: Staph aureus enterotoxins may elicit an immunemediated response in certain individuals with chronic sinusitisand polyps. This response may act through type I IgE allergyand/or a T-cell mediated superantigen response, contributing tothe inflammation that drives chronic sinusitis with polyps.

9:42 am


9:45 am

Break with Exhibitors39

Antimicrobials and RS

Moderator

Michael Siller, MD

10:15 am

Penetration of Telithromycin (HMR 3647), aNew Ketolide, into Sinus Tissue in Patients

Undergoing Sinusectomy

J.M. Klossek, MDE. Serrano, MD

R. Peynegre, MDPoitiers, France

Background: A 5-day course of telithromycin 800 mg once dailyhas demonstrated efficacy and safety in acute sinusitis. The aimof this open, multicenter, randomized, parallel-group study wasto assess telithromycin diffusion in maxillary sinus tissue.

Methods: 25 adult patients undergoing endoscopic endonasalsurgery for nasal polyposis received telithromycin 800 mg orallyonce daily for 3 days before surgery. Sinus tissue samples werecollected 2, 3, 4, 5, 12, 24 hours (H) and blood samples 2, 4, 12, 24H after the last intake respectively. Tissue and plasma concentra-tions were determined by microbiological assay.

Results: 21/25 patients were eligible for pharmacokinetic analy-sis.

Mean (± SD, [95% CI]) sinus tissue concentrations oftelithromycin (mg/kg) were as follows: 6.60 ± 3.48 [2.28;10.93] at2 H (n=5), 5.54 ± 1.68 [2.86;8.22] at 3 H (n=4), 6.96 + 1.58[5.00;8.92] at 4 H (n=5), 5.44 ± 0.97 [3.90;6.98] at 5 H (n=4), 3.98 ±1.93 [1.59;6.38] at 12 H (n=5), 1.58 ± 1.68 [-0.18;3.34] at 24 H(n=6). Mean (± SD, [95% CI]) plasma concentrations oftelithromycin (mg/L) were as follows: 1.05 ± 0.22 [0.51;1.58] at 2H (n=3), 1.27 ± 0.50 [0.47;2.06] at 4 H (n=4), 0.29 ± 0.11 [0.16;0.42]at 12 H (n=5), 0.04 ± 0.01 [0.02;0.05] at 24 H (n=5). Sinus/plasmaconcentrations ratios ranged from 4 to 6 at 2 H and 4 H.

Conclusions: A 3-day course of telithromycin 800 mg orallyonce daily achieves high sinus tissue concentrations, higher thanMIC values for the key bacterial pathogens responsible for acutesinusitis.

40

10:22 am

Middle Meatus/Sinus Culture — Does ItChange Therapy?

Berrylin J. Ferguson MDShalini Kansal, MD

Pittsburgh, PA

Background: Infectious rhinosinusitis can be viral or bacterial.The recent increase in antimicrobial resistance makes empiric se-lection of an appropriate antibiotic problematic. The senior au-thor’s current practice is to endoscopically culture all patientswith possible infectious rhinosinusitis. This retrospective studyassesses the impact this practice has on patient management.

Design: Retrospective chart review

Intervention: Examination of culture results obtainedendoscopically from the middle meatus or a specific sinus andassessment of whether antibiotic treatment was altered based onculture results.

Results: 22 charts were retrospectively reviewed. In 5 patients,no pathogenic bacteria were isolated and no antibiotic treatmentwas initiated. In 4 patients, pathogenic bacteria were isolated,and the appropriate antibiotic, which was implemented prior toculture, was continued. In 4 patients, pathogenic bacteria wereisolated, and the patient’s initial antibiotic was switched basedon sensitivities. In 6 persistently symptomatic patients, an anti-biotic was instituted based on specific bacterial sensitivities afterculture results were available. In 3 cases, patients improved fol-lowing sinus irrigation and topical antibiotics and despite isola-tion of pathogenic bacteria, no antibiotic was initiated.

Conclusions: In 10 of 22 patients (45%) antibiotics were changedor initiated based on endoscopically obtained culture results.

Conflict details: Berrylin J. Ferguson MD — Consultant forGlaxosmith Kline, Aventis, Pfizer; Research Support fromAventis; Speaker’s Bureau of Glaxosmith Kline, Aventis.

41

10:30 am


10:35 am

Patient Advocacy Committee/Membership/Education Committee Presentations

Moderators

Committee Chairs


42

Image Guidance and Imaging

Moderators

Martin Citardi, MDBrent Senior, MD

11:05 am

Evaluation of the Endoscopic Sinus SurgerySimulator (ES3) as a training device

Marvin P. Fried, MDWalter Ralph, MD, PhD

Jose I. Uribe, MDBronx, NY

As an initial step in evaluating the efficacy of training otolaryn-gology residents on the endoscopic sinus surgery simulator(ES3), we have assessed the ability of the ES3 to train persons in-experienced in sinus surgery (medical students) to perform sim-ulated procedural tasks of endoscopic sinus surgery. In thenovice mode (a training mode of the ES3 in which 3D abstractimages are used to teach the use of endoscopic surgical equip-ment) 11 randomly selected medical students displayed a steeplearning curve within 3-5 trials on the simulator and, after an ad-ditional 4-5 trials, reached a plateau in their learning curves towithin 90% of that of experienced sinus surgeons. In the inter-mediate mode (a training mode of the ES3 in which endoscopicsinus surgery is performed on a simulated patient with realisticsinus anatomy) a similar trend existed where 5 students wereable to plateau their learning curve to within 80% of that of ex-perienced surgeons after 3 to 5 trials within a 2 to 6 week train-ing period. Of note was the observation that medical students,who had 3-4 continuous weeks of novice or intermediate modetraining interrupted with an interval of 1-2 months, were able toresume their training without deviation from their prior learningcurves. Students who were on the steep slope of their curveprior to the interruption returned to that part of the curve in amanner similar to those who never had an interruption. Theseresults support the conclusion that (1) intensive, proctored train-ing on the ES3 can train inexperienced persons to perform simu-lated endoscopic sinus surgery within a reasonableapproximation of the performance of experienced sinus sur-geons on the ES3 and (2) the training that an inexperienced per-son receives on the simulator is not short-term, but is retainedover a period of at least 1-2 months.

43

11:12 am

CT Generated Templates — A NewApproach to Frontal Sinus Osteoplastic Flap

Surgery

John L. Fewins, MDRandal A. Otto, MD

San Antonio, TX

Objectives: To present a new technique for frontal sinus tem-plate creation used in osteoplastic flap surgery which obviatesthe need for the traditional 6 foot Caldwell radiograph.

Study Design: A prospective study was conducted using tem-plates created from human cadaver skulls.

Methods: Seventeen human cadaver skulls were studied. Usingdigital addition algorithms of sequential coronal CT images ofthe frontal sinus to create a composite image, an image isprinted to 1cm=1cm scale. A frontal sinus template was createdusing this processed image and compared to a control 6-footCaldwell plain film.

Results: Seventeen human cadaver skulls were studied. Onewas excluded secondary to an agenic frontal sinus. Three wereexcluded due the inability to clearly visualize landmarks on theCaldwell projections. The mean variance between correspondingvertical points on the templates was.7mm with a standard devia-tion of.7mm. The mean variance between horizontal points was1.2mm with a standard deviation of 1.4mm. The mean differencein width was 2.5mm. The plain film templates were alwayswider than the CT generated templates.

Conclusions: The CT generated frontal sinus templates wereeasily created, practical, and precise. They obviate the need foradditional imaging and minimize the potential errors commonlyassociated with six-foot Caldwell templates. Additionally, theyare more easily obtained in severely injured patients who maybe unable to stand for standard 6 foot Caldwell radiographs.Our results indicate that there is negligible variation in size be-tween CT and plain film generated templates.

Key Words: frontal sinus, osteoplastic flap, Caldwell

11:20 am


44

11:30 am

Economic Analysis of the Use of LimitedCoronal CT Scans in the Management of

Sinusitis

Christine B. Franzese, MDScott Stringer, MD

Jackson, MS

Objectives: As medical costs increase, less expensive alterna-tives to standard diagnostic tests are sought to reduce the eco-nomic burden placed on society. One alternative is using limited,non-consecutive cut computed tomography (CT) scans for theevaluation of sinonasal disease. This study evaluates thecost-effectiveness of utilizing limited CT scans instead of full se-quence CT scans in the diagnosis and management ofrhinosinusitis.

Methods: A Medline search was performed to obtain data forthe sensitivity and specificity of limited CT scans, the prevalenceof abnormal CT scans, and recommendations on using limitedCT scans for operative management. A standardcost-effectiveness analysis including a sensitivity analysis wasperformed using a hypothetical population of patients with si-nus complaints who failed prior appropriate medical therapy.

Results: At baseline, the limited CT scan was found to be lesscost-effective than the full CT scan, costing $217.13 more per cor-rect diagnosis. The sensitivity analysis demonstrated thatchanges in the prevalence of abnormal CT scans and the percent-age of surgeons who would operate using a limited scan had thegreatest impact on cost, while changes in the price of the full CTor limited CT scan had the least effect.

Conclusions: This study finds the use of limited CT scans to beeconomically unsound as a method to reduce costs in the definedpopulation. Published literature recommends obtaining a full CTscan prior to operative management. Basing intervention on lim-ited CT scans increases the possibility of erroneous diagnosesleading to either excessive or inadequate treatment of patients.

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11:38 am

An Endoscopic Study of the Neural Anatomyof the Ptergomaxillary Fossa

Jonathan Mellema, MDThomas A. Tami, MD

Cincinnati, OH

Introduction: Utilizing an endoscopic approach, lateralsphenoid air cells and terminal branches of the internalmaxillary artery can often be accessed through theptergomaxillary fossa, however injury to the infraorbital nerve(V2) and greater palatine nerve (GPN) can occur if the anatomyof this region is not clearly understood. This study was under-taken to define the pathway of V2 and the GPN and to identifylandmarks useful in preventing their injury.

Methods: Six cadaveric heads were used to endoscopically dis-sect and examine eleven pterygomaxillary fossae. An additionallatex injected cadaveric head was sectioned coronally and dis-sected bilaterally. The relationships between the vascular, neuro-logic and bony structures and foramena were noted anddescribed.

Results: All specimens studied maintained consistent relation-ships. The sphenopalatine and posterior nasal arteries crossnearly perpendicular and just superficial to the GPN. The GPNtraveled anteriorly and inferiorly to reach the greater palatine fo-ramen. The lateral wall of the canal ranged from a thin bonycovering to complete dehiscence and was thinnest as it crossedthe inferior turbinate and approached the foramen. The foramenrotundum was consistently located lateral and superior to thesphenopalatine foramen near the roof of the maxillary sinus.

Conclusions: When surgically approaching thepterygomaxillary fossa, injury to V2 and the GPN can beavoided if specific anatomical relationships are understood. Theforamen rotundum, V2, GPN and internal maxillary artery allhave specific anatomical relationships which can be used to suc-cessfully and safely navigate through this complex anatomic re-gion.

Conflict details: Medtronic/Xomed provided surgical and videoequipment to perform the anatomic dissections.

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11:46 am


11:54 am

Closing Remarks

Donald Lanza, MDJames A. Hadley, MD

12:00 pm

Adjourn

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POSTER PRESENTATIONS

Aeroallergen Hypersensitivity: Comparingpatients with Nasal Polyps (NP) to those

with Allergic Rhinitis (AR)

Janine VanLancker, MDAnne Ditto, MD

Paul Yarnold, PhDKristen Seiberling, MD

Chicago, IL

Background: IgE mediated allergy has not generally been con-sidered to be important in the pathogenesis of nasal polyps, inspite of elevated IgE in polyp exudates, tissue eosinophilia anddegranulated mast cells. In previous reports, patients with nasalpolyps were more likely to have positive skin tests to perennialthan to seasonal allergens. It is postulated that nasal polyps re-sult from the constant nature of perennial allergen exposure.

Objectives: To compare the prevalence of sensitization to 6aeroallergens in a group of nasal polyp(NP) patients, a group al-lergic rhinitis(AR) patients, and those subjects with positive skintests in the National Health and Nutrition Evaluation Survey(NHANESII).

Methods: Twenty-five consecutive nasal polyp patients evalu-ated over a 3 month period of time at Northwestern Sinus andAllergy Center, in addition to 50 of the allergic rhinitis patientsevaluated over the same time were randomly chosen. All wereskin tested with the following antigens: dog, cat, dust mite,grass, tree, and ragweed. (ALO; Columbus Ohio). Publishedskin test data from the NHANESII study of 14,367 individualswas also obtained.

Results: The percent of NP patients, AR patients, andNHANESII subjects with sensitization to perennial allergenswas 72%, 96%, and 7.6% respectively. The difference between theAR and NP patients was statistically significant. (p=0.006)

The percent of NP, AR, and NHANESII subjects sensitized toseasonal allergens was 84%, 82%, and 17.7%. There was no sta-tistical difference between the AR and NP patients.

Conclusions: While the AR and NP patients had similar levelsof reactivity to perennial and seasonal allergens, the NHANESIIgroup was more than twice as likely to be sensitized to a sea-sonal allergen. The NP and AR groups were similar in preva-lence of reactivity to seasonal allergens, but the NP patients inour population were actually less likely to be sensitized to pe-rennial allergens than individuals with AR.

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Change in Olfaction After Sinus Surgery

Prajoy Kadkade, MDHector Rodriguez, MD

Jeffrey Ahn, MDLanny G. Close, MD

New York, NY

Background: Functional endoscopic sinus surgery (FESS) isnow the surgical procedure of choice for treating medi-cally-refractory chronic sinusitis in patients of all ages. In FESS,it is common practice to medialize the middle turbinates by su-turing the middle turbinates to the septum. There is anecdotalevidence that suture-medializing the middle turbinates ad-versely affects olfaction.

Objectives: To objectively evaluate olfaction postFESS/septoplasty with suture-medialization of the middle turbi-nates.

Methods: University of Pennsylvania Smell Identification Tests(UPSIT) were administered preoperatively and postoperativelyto 20 patients undergoing FESS/septoplasty for medi-cally-refractory chronic sinusitis. All patients had reported sub-jective olfactory dysfunction preoperatively. Half of thesepatients underwent suture-medialization of the middle turbi-nates as part of the procedure. The average age was 40 yearswith approximately 3:2 male: female ratio in both groups.

Results: There was an average increase in sense of smell post-operatively in both groups based on UPSIT. No significant dif-ference in sense of smell was detected in patients whounderwent suture-medialization of the middle turbinates com-pared with patients who did not have suture-medialization.

Conclusions: There is no detriment to olfaction with su-ture-medialization of the middle turbinates.

Patient Preference for Outcomes Measuresof Rhinitis

Ilknur Haberal, MDJacquelynne P. Corey, MD

Chicago, IL

Objectives: Our aim was to determine patient preference forvalidated allergic rhinitis questionnaires. Two questionnaireswere evaluated: the FNQ (Fairley Nasal Questionnaire), and theSNOT-20 ( 20 Item Sino Nasal Outcome Test).

Study design and Setting: A prospective study was performedon 25 patients with rhinitis symptoms. They were given the

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SNOT-20 and FNQ concurrently and asked to complete thequestionnaires. They were asked which questionnaire they feltmost accurately depicted their symptoms.

Results: 48% of the patients were females whereas 52% weremales. 22 (88%) of them had allergic rhinitis, 2 (8%) had chronicsinusitis, 1 (4%) had acute sinusitis, 8 (32%) had allergic conjunc-tivitis, 2 (8%) had obstructive sleep apnea (OSA), 1 (4%) septalperforation, 2 (4%) septal deviation and 2 (8%) had asthma.Among these patients with proved and suspected allergic rhini-tis, 17 (68%) prefered SNOT-20, saying that it was more detailedand it reflected their symptoms much better.

Conclusions: The SNOT-20 is a preferred testing method for pa-tients with symptoms of allergic rhinitis, a chronic disorder. TheFNQ seemed better for acute symptoms.

Discussion and Significance: The recent trend has been toshorten questionnaires as it was assumed that patients prefershorter questionnaires. In this study, the longer questionnairewas preferred because it was felt to be more complete and moreclosely approximated their symptoms.

Results of Endoscopic Surgery of ChoanalAtresia Through Transnasal Approach

Mohammad Hossein Baradaranfar, MD.Farhad Fatehi, MD.

Yazd, Iran

Choanal atresia is a complete blockage of communication be-tween nasal cavity and nasopharynx. Clinical presentation de-pends on the type of anomaly. In unilateral atresia, there may beno symptoms until puberty but unilateral rhinorea in a childshould raise suspicion of choanal atresia.

Clinical signs are usually present at birth in bilateral atresia, in-cluding recurrent cyanosis that is relieved by crying. Between1997 and 2000, in the Amiralam hospital (Tehran) and ShahidRahnemoun hospital (Yazd), 18 Patients with choanal atresia un-derwent transnasal Endoscopic surgery.

Mean age was 7.3 years with a range of one month to 16 years.14% of patients had bilateral atresia and the remaining 86% hadsingle sided atresia. Of those with single sided atresia, 70% wereon the right side and 30% on the left side. 43% had membranousatresia and 59% were bony atresia.

In bony atresia it was opened by micro-drilling and in membra-nous ones, it was opened by curette and circular punch. Stenttube was placed for all of them.

Mean follow up time was 38 months. 12 patients had completesuccess with both choanae open but in 4 patients nasal obstruc-

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tion recurred, two of them underwent revision and the other 2patients refused revision surgery.

No complications occurred in patients. Considering these resultsin seems that endoscopic surgery of choanal atresia throughtransnasal approach is a good method, which due to excellentvisualization of the field, yields successful results.

Transnasal Endoscopic Repair of OrbitalBlow out Fracture


Yazd, Iran

Orbital blow out fracture is defined as fracture of one of orbitalwalls without orbital rim involvement. It is more common in or-bital floor. Prolapse of orbital contents into maxillary sinus cancause ophthalmic complaints.

Clinical signs of orbital blow out fracture include: eyelidechymosis, diplopia, restriction of eye movements, enophtalmia,and occasionally sensory deficits in infraorbital nerve territory.

Here we describe a case of orbital blow out fracture with in-volvement of orbital floor after trauma who presents with eyelidechymosis, diplopia, exophtalmous and impairment of upwardgaze. In coronal high resolution CTscan there was fracture of or-bital floor with prolapse of orbital contents into maxillary sinus,but without fracture of lamina papyracea.

Under general anesthesia with transnasal endoscopic approach,a wide middle meatal antrostomy was created and after removalof bony fragments, orbital contents were released from periph-ery and returned into orbit. A Foley catheter was introduced intomaxillary sinus and inflated to support the repaired area. It re-mained in place for 2 weeks. After operation, all signs of fractureimproved and post-op CTscan approved clinical improvement.It seems that transnasal endoscopic approach with better visual-ization, less bleedings and no need for foreign material such assilastic is a choice for repair of orbital blow out fracture thantrans-orbital or trans-antral methods.

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Endoscopic Resection ofa Maxillary Sinus Ameloblastoma

Lance A. Manning, MDEric J. Moore, MD

Rochester, MN

Ameloblastoma is an uncommon, benign, locally invasive tumorrepresenting 1% of all jaw tumors. It has a predilection for themandible and is typically slow-growing in nature. Twenty per-cent of these tumors occur in the maxilla, and when this hap-pens, the standard therapy is wide local resection. We present acase of an elderly patient that presented with symptoms of nasalcongestion and rhinorrhea. CT scan confirmed the presence ofan expansile mass with bone deformation. Endoscopic biopsyconfirmed the presence of ameloblastoma and a partial medialmaxillectomy was performed endoscopically instead of the tra-ditional open surgical treatment. Surgical approach and techni-cal issues are discussed. As endoscopic technologies, experience,and techniques continue to evolve, endoscopic treatments aug-ment the breadth of treatment options available to the skull basesurgeon.

Saddle Nose Repair with “Modified CrossedFlying Wing” Method (A New Approach)


Yazd, Iran

The hallmark of saddle deformity is an abnormally concave na-sal dorsum in profile. The fundamental defect is a lack of archi-tecture in the nasal dorsum, which may involve the bony orcartilaginous nasal vault.

Depending on the degree of architectural loss several associatednasal defect may be seen commonly with the saddle nose defor-mity such as tip-lip complex abnormalities, projection defectsand so on.

Numerous etiologies of the saddle nose are described most com-monly trauma or previous rhinoplastic surgery but congenitaldefect, infectious diseases, syphilis and soon are other probableetiologies.

The treatment plan first must insure that the underlying etiologyis addressed. Correction of the saddle defect almost universallyinvolves augmentation of the nasal dorsum with a filler materialto replace the lost framework. Augmentation materials maybebroadly categorized as autografts, homografts and alloplasts. Anideal augmentation material would approximate closely the

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shape, consistency and strength of the deficient nasal frame-work. It would be easily obtainable capable of being shaped andcost-effective. Finally it would provoke minimal tissue reactivityand resist tissue extrusion, or resorption.

None of augmentation materials is correct for all circumstancesand a myriad of materials have been used over the years. Over-all autograft cartilages (Septal, auricle or lower lateral) if avail-able are preferred over other materials.

Modified crossed flying wing is a new method that usesautogenous lower lateral cartilage for repair of mild to moderatecases of saddle nose deformity. We used this method in some pa-tients with traumatic or post-rhinoplasty saddle nose. UnderG/A and with open approach the cephalic portion of lower lat-eral cartilage was separated, crossed and sutured to nasal boneperiosteum. The mean follow up of patients was 3 years withoutany complication of recurrence.

It seems that this method is a suitable mean for mild to moder-ate saddle nose without any sequel, further deformity or donorsite morbidity.

Malignant Solitary Fibrous Tumor of TheEthmoid Sinuses: A Case Report

Joshua A. Gottschall, MDKathleen L. Yaremchuk, MD

Michael D. Linden, MDDetroit, MI

Introduction: Solitary fibrous tumor (SFT) is a rare spindle cellneoplasm, originally described as a tumor of the pleura.Extrapleural SFT, including those arising in the head and neckare exceedingly uncommon. To date, only 13 cases of sinonasalSFTs have been reported. We believe this to be the first exampleof a malignant solitary fibrous tumor of the head and neck andparanasal sinuses.

Methods: Case report.

Results: A 71 year old male presented with 5 month history ofnasal obstruction and snoring. He has no history of sinusitis orallergic rhinitis, yet is found to have bilateral nasal polyposis.After failure of medical therapy, nasal endoscopy is performed.An unusual mass is found in the left ethmoid sinus.Histopathological evaluation reveals a patternless cellular ar-rangement with poorly defined eosinophilic cytoplasm. Focal ar-eas of prominent branching vessels resemblehemangiopericytoma. Immunostaining is positive for CD34 andVimentin, and negative for S100, LCA, CK, HHF-35, EMA, andFactor 13A. The diagnosis of malignant SFT is made with thefinding of 8 mitotic figures per 10 high-powered fields counted.

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Review of the literature reveals this to be the first documentedcase of malignant solitary fibrous tumor of the head and neckand paranasal sinuses. Management including natural history isreviewed and histologic and radiographic examples are pro-vided.

Conclusions: This case report serves to document the first caseof malignant solitary fibrous tumor of the head and neck. Theseexceedingly rare tumors must be included in the differential di-agnosis of nasal neoplasms. We also emphasize the importanceof specimen collection on routine endoscopic sinus surgery.

Endoscopic Repair of CSF Rhinorrhea andEncephalocele: A Case for Intrathecal

Fluorescein Localization

Derek Kofi O. Boahene, MDDavid A. Sherris, MD

Rochester, MN

Introduction: Endoscopic repair of CSF rhinorrhea has gainedincreased acceptance. Successful outcomes depend on the pre-cise intraoperative localization of the leakage site. We present acomplex case were the use of intrathecal fluorescein allowed theprecise intraoperative localization of CSF leakage site to the an-terior ethmoid whereas a preoperative indium -111 DTPAscinticisternogram falsely suggested the sphenoid sinus.

Methods: A 47 years-old female presented with left-sided clearrhinorrhea 3 years following primary radiation treatment of anoptic sheath meningioma in the region of the left sphenoid si-nus. Follow-up MRI showed no recurrence of the meningioma.The nasal discharge was positive for beta-2 transferrin. Preoper-ative indium -111 DTPA cisternogram revealed a high count inthe left sphenoid sinus consistent with the patient’s previoushistory. An endoscopic repair of a potential sphenoid sinus de-fect was planned. Intrathecal fluorescein was used to facilitateintraoperative identification of the leakage site. The leftsphenoid was however negative for any dye leak or dehiscence.

Results: The CSF leakage site was localized to the anteriorethmoidal roof with intrathecally injected, CSF diluted 5%fluorescein. An associated encephalocele was identified and re-moved without sequelae. The leak was successfully repaired us-ing tissue glue and a composite graft of uncinate mucosa andbone.

Conclusions: Although preoperative identification of CSF fistu-las with cisternograms is useful, the addition of intrathecalfluorescein allows a precise live-time intraoperative localizationof the defect, which may prevent the performance of the wrongrepair procedure.

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Treatment of Velopharyngeal Incompetencewith Injectable Hydroxylapatite

Carl H Snyderman, MDPittsburgh, PA

A variety of surgical techniques have been used for the treat-ment of velopharyngeal incompetence (VPI), including palatalflaps and tissue implants. Calcium hydroxylapatite ceramic(HAC) is a synthetic material that is biocompatible and does notelicit a foreign body reaction. It has been used to augment softtissues and maintains its volume. The first reported case ofinjectible HAC for the treatment of VPI is presented here. A53-year-old female developed VPI following a transoral/transpalatal decompression of the cervical spine. Symptoms ofnasal reflux and hypernasal speech resolved following endo-scopic injection of the nasopharyngeal tissues with HAC 13 and18 months following her initial surgery. Long term persistence ofthe injected implant has been demonstrated radiographically. In-jectable HAC provides a simple and effective technique for thetreatment of VPI in selected patients.

MRI Findings in the Evaluation of TraumaticAnosmia

Jeffrey B. Wise, MDNatasha Mirza, MD

Philadelphia, PA

Introduction: Head trauma is a common etiology of anosmia,but diagnosis is typically late, owing to the more life-threateningsituation of an acute head injury. We present a case report in-volving a patient who sustained a closed head injury with theisolated neurological sequella of permanent anosmia, diagnosedearly with brain imaging and an olfactory evaluation. MRI find-ings in the setting of acute olfactory region trauma are discussedin this report.

Methods: Case report. CT was a 34 year old woman who pre-sented to a local emergency room with head trauma secondaryto being struck by an automobile while riding a bicycle. Heronly symptom was a change in sense of smell noticed afterabout 3-4 days.

Results: MRI of the brain obtained immediately post traumademonstrated hemorrhage with surrounding edema in the gyrusrectus and the region of the olfactory bulbs and tract bilaterallycompatible with hemorrhagic contusion. A follow- up MRI per-formed after one year demonstrated malacia in the above men-tioned areas with associated volume loss, in an appearance

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suggestive of chronic contusion. Formal olfactory testing dem-onstrated bilateral total anosmia.

Conclusions: Anosmia is a potential complication of headtrauma. Conventional MRI, which is readily available at mostmedical centers, serves as a valuable tool for predicting olfactorytrauma, and may serve to correlate clinical progression. Such test-ing may enable early consultation of an Otolaryngologist, formalolfactory testing, and early patient counseling regarding anosmia.

Lipoma of the Nasal Dorsum, A UniquePresentation of Common Neoplasm

Shepherd G. Pryor, MDLaura J. Orvidas, MD

Eric J. Moore, MDRochester, MN

Introduction: Lipomas are the most common neoplasm ofmesenchymal origin and more than 10% arise in the head andneck. We present the first known case of a lipoma arising fromthe nasal dorsum.

Methods: Case report and literature review

Results: The lipoma was completely excised via an externalseptorhinoplasty approach providing an excellent cosmetic result.

Conclusions: This is the first known presentation of a lipoma ofthe nasal dorsum. We describe the presentation of this unusuallesion, describe the radiographic characteristics which differenti-ate it form other neoplasms in this area, and recommend a mini-mally invasive method of treatment.

Bacteriology of the Patients with ChronicSinusitis of Whom Had Been Medically andSurgically Treated Due to Chronic Sinusitis

Altan Yildirim, MDSivas, Turkey

Chronic sinusitis is a disease that afflicts a significant percentageof the population and causes considerable long-term morbidity.The common use of multiple broad specturum oral antibiotics andperforming endoscopic sinus surgery to treat this condition mightcause an alteration in the pathogenes that promote persistence ofchronic sinusitis. Fortyeight culture positive patients with chronicsinusitis of whom had been medically and surgically treated dueto chronic sinusitis were bacteriologically evaluated. Swab speci-

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mens of middle meatus and sphemoetmoid recess were asepti-cally obtained endoscopically and cultured for aerobs.Coagulase-negative staphylococci were the most common isolates45.8% followed by streptococcus pneumonia16.7%,enterobactericea 16.7%, staphylococcus aureus 10.4%, pseu-domonas aurogenosia 10.4%. Coagulase-negative staphylococcusis the most frequently isolated organism in our study as in manyother studies of nonoperated patients. Despite the significant pre-dominance of this organism has always been assumed to be a con-taminant and it’s presence in culture has been discounted.Coagulase-negative staphylococcus may be a pathogen in chronicsinusitis process and sensivities should be obtained of this isolatefor evaluation and possiable teatment of the disease.

An Initial Report of a Cranial Pin System forFrameless Image Guidance

Mark J. Burstein, BARichard A. Lebowitz, MD

Joseph B. Jacobs, MD (corresponding author)New York, NY

Introduction: The use of an intraoperative navigation deviceimproves surgical accuracy, helps identify anatomic landmarksand can minimize the risk of complications during surgery ofthe paranasal sinuses and skull base. Despite these benefits ofimage guidance, its use is limited by the headset, which pre-cludes external surgical access. We report the successful utiliza-tion of a cranial pin (AXCESS(tm) System) that is placed into theouter table of the calvarium during surgery. This eliminates theneed for a headset, permitting unencumbered external surgicalaccess.

Methods: Following the induction of general anesthesia, the pa-tient’s temporal scalp is prepped and draped. A 2-3 cm incisionis made, and the calvarium is exposed. A drill hole is made us-ing a special guarded bit and the cranial pin is placed, using acustom driver, included with the AXCESS TM system. A trans-mitter is then attached to the pin, and calibration is performed.Following a fast fiducial registration and verification, the head-set is removed, and intraoperative tracking can then be accom-plished.

Results: Accuracy of intraoperative localization was noted to besimilar to published reports using the InstaTrak(r) System with aheadset. There were no complications associated with placementof the cranial pin. Patients reported only minimal postoperativediscomfort related to the 2-3 cm. temporal scalp incision.

Conclusions: The cranial pin adaptation for the InstaTrak(r)System combines the benefits of surgical navigation with exter-nal surgical access to the paranasal sinuses and base of skull.

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Pyogenic Granuloma

Han-Soo BaeLin, Ho-Sheng

Detroit, MI

Introduction: Nasal pyogenic granuloma is an uncommon le-sion which presents as a vascular nasal mass. There are reportsof both anterior and posterior location. The etiology is believedto be traumatic or related to pregnancy.

We report two cases—one pregnancy related and the other traumatic.

Study Design: Case report and review of literature

Results: 33 year old pregnant woman presented with rightsided epistaxis and controlled by cauterization by the Emer-gency Department. Since the cauterization, she developed rightsided nasal obstruction with a friable tissue. After her delivery,the lesion was biopsied in the clinic which revealed a pyogenicgranuloma. She was then taken to the OR for total endoscopicresection.

Our second patient is a 50 year old presented with a two year his-tory of right nasal obstruction and multiple episodes of intermit-tent epistaxis. Physical exam revealed a verrucous-looking massoccupying the entire anterior nasal cavity attached to the septumby a narrow stalk. CT scan demonstrated anterior nasal mass 3 by2 cm. Biopsy was performed in the office which showed featuresconsistent with pyogenic granuloma. The patient subsequentlywas taken to OR for total endoscopic resection

Conclusions: The etiology of pyogenic granuloma is unclear;however, trauma and hormonal changes seem to be contributingfactors. Management consists of total resection and observation.

Subperiosteal Orbital Abscess: Medical orSurgical Treatment?

Christopher L Brown, MDScott M Graham, MD

Nancy M Bauman, MDMark Griffin, MD

Iowa City, IA

Introduction: Controversy exists about the optimal manage-ment of subperiosteal orbital abscesses ( SPOAs). Some advocateimmediate surgical drainage. Others recommend medical man-agement with surgery reserved for non responders. We hypothe-sized that patients who could be managed without surgery hadidentifiable features on presentation.

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Methods: A retrospective chart review was performed. All pa-tients were 18 years and younger. Findings consistent with aSPOA were present on CT imaging. Patients were divided intotwo groups;Group 1 had medical treatment alone while group 2had either open or endoscopic abscess decompression surgerywithin 24 hours of admission.

Results: 39 patients were identified. 17 ( group 1 ) received en-tirely medical treatment while 22 ( group 2 ) had surgery. All pa-tients had resolution of their SPOA. The following variablesattained significance: group 1 presented younger ( 5 vs. 13 years,p = 0.0003 ), had less ophthalmoplegia ( 1.0 vs. 2.3, p = 0.017 )and spent less time in hospital ( 6.5 vs. 13 days, p = 0.011 ). Thefollowing variables did not obtain clinical significance; gender,side of abscess, temperature, total white cell count, neutrophilcount, chemosis, visual acuity and proptosis. Culture reportswere predominantly no growth ( 10/25 ) and streptococci ( 7/25). There were no surgical complications.

Conclusions: A subset of patients with SPOAs can be managedmedically, particularly if younger and with minimalophthalmoplegia. Close observation of these patients for possi-ble deterioration and need for surgical management is required.

Recovery of Olfaction After EndoscopicSinus Surgery for Chronic Sinusitis

Debbie A. Mouadeb, MDSteven E. Sobol, MD, FRCS(C)Saul Frenkiel, MD, FRCS(C)

Montreal, Canada

Background: Smell recovery in patients with chronic sinusitiswho have undergone functional endoscopic sinus surgery(FESS) appears to be quite variable. Few studies have assessedthe effect of this treatment on the sense of smell.

Objectives: We hypothesized that restoration of smell may de-pend on pre-existing factors such as the extent of disease, the se-verity of nasal polyps, and the presence of Samter’s triad. Thepurpose of this study was to analyze these factors prospectively,with respect to smell recovery after FESS.

Methods: 82 patients who underwent FESS participated in thisstudy. Patients were evaluated pre-operatively with a nasal and si-nus survey, physical examination, allergy testing, and computer to-mography. Visual analogue scoring was performed pre-operatively,and repeated at 5 post-operative intervals over 2 years.

Results: At 4-12 weeks post-operatively, significant improve-ment was noted in the majority of patients’ subjective olfactoryability (mean relative improvement 58%). However, patientswith polyps, more severe sinusitis, and asthmatics all showed

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less relative improvement then their counterparts. Over twoyears, all patient subgroups showed evidence of some deteriora-tion from their first post-operative visit, but patients withSamter’s triad showed the most impressive deterioration, withan initial mean relative improvement of 64% at the firstpost-operative visit to only a 25% mean relative improvementfrom pre-operative baseline at 12 months.

Conclusions: FESS with post-operative nasal steroid spray, per-formed in patients with chronic rhinosinusitis, significantly im-proves subjective olfactory ability. However, variability is presentand appears to be correlated with certain pre-operative risk factors.

Embolization for the Treatment of IdiopathicPosterior Epistaxis

Theresa A. Gurney, MDChristopher Dowd, MD

Andrew Murr, MDSan Francisco, CA

Objectives/Introduction: Posterior packing, ligation andcautery are long-standing methods for treatment of idiopathicposterior epistaxis. In the last decade, embolization has becomemore frequently employed for management. This study presentsour experience with embolization for treatment of idiopathicepistaxis from 1988 to present.

Methods: We present a retrospective chart review of all patientsundergoing embolization for posterior epistaxis treated by oto-laryngology - head and neck surgery, neurology and/orinterventional neuroradiology services at a tertiary care facility.The charts of patients who presented with idiopathic posteriorepistaxis were reviewed in detail.

Results: Seventy-four patients were treated with embolizationfor posterior epistaxis. The majority were idiopathic presenta-tions of posterior epistaxis (30, 41%). In decreasing frequency,the following underlying conditions were found: juvenile naso-pharyngeal angiofibroma (15, 20%), malignancy (6, 8%),post-surgery (5, 7%), arteriovenous malformation (4, 5%),Osler-Weber-Rendu syndrome (4, 5%), trauma (4, 5%) and idio-pathic thrombocytopenic purpura (1, 1%). Seventeen men (57%)and 13 (43%) women presented with idiopathic epistaxis. Themean age of presentation was 67 years with a range from 44 to87 years. The majority had failed packing and many were re-ferred from other institutions for refractory epistaxis. Four (13%)had recurrent epistaxis within one month requiring either repeatembolization (3) or treatment by other modalities (1). Hyperten-sion, diabetes mellitus and intake of anticoagulant medicationswere associated risk factors for idiopathic epistaxis.

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Conclusions: Embolization is an effective modality for treatmentof idiopathic posterior epistaxis. Occasional recurrences may ne-cessitate repeat embolization or treatment by other means.

Endoscopic Sinus Surgery in Patients withChronic Hepatic Failure Waiting Liver

Transplant

John M. DelGaudio, MDAtlanta, GA

Introduction: Because of the need for postoperativeimmunosuppression, patients with chronic liver failure requir-ing transplantation must be free of infection to maintain activestatus on the transplant list. These patients present significantsurgical risks due to coagulopathy. Here we present our experi-ence with endoscopic sinus surgery for medically refractory si-nusitis in this patient population.

Methods: A prospective case series of 7 patients undergoing 10surgeries from May 2001 to October 2002. Patients were evalu-ated for operative blood loss, perioperative blood product use,complications, and the need for revision surgery.

Results: All patients were given preoperative blood product in-fusions. 7 of 10 cases (5 patients) had elevated prothrombintimes. Fresh frozen plasma (FFP) was given in all cases (average2.44 U/case). 5 cases received preoperative platelets forthrombocytopenia (42-78,000/ul). Two patients each requiredpreoperative transfusions of 2 units of packed red blood cells(PRBCs) for anemia of chronic disease. Operative blood lossranged from 200-1500cc with an average of 533cc. One case hadto be stopped before completion because of bleeding obscuringvisualization. The 2 cases with the greatest blood loss were inpatients with the most severe liver and sinus disease. These 2patients (4 cases) required the only postoperative transfusions,use of packing, and hospital stays longer than 1 night, and re-quired revision surgery within 2 months of the initial proceduredue to persistent disease. All patients were returned to activestatus on the liver transplant. No major complications occurredin this group of patients.

Conclusions: Patients with chronic hepatic disease awaitingliver transplant can be successfully treated with endoscopic si-nus surgery. Preoperative use of FFP and platelets is always nec-essary and postoperative blood products may be required withworse disease. Significant perioperative bleeding may not beavoidable. Patients should be counseled on the possible need foradditional procedures to adequately clear disease.

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Suggestions From the Senior Surgeon toPerform an Intranasal Endoscopic

Duraplasty

Paolo Castelnuovo, MDSilvia Mauri, MD

Maurizio Bignami, MDGiovanni Delù, MD

San Donato Milanese, Italy

Introduction: endoscopic intranasal repair of cerebrospinal fluidrhinorrhea is becoming a common procedure. Methods: the purposeof the authors is to perform a critical analysis of their personal experi-ence on 90 cases of cerebrospinal fluid leaks: 79 treated with theintranasal endoscopic approach, while 11 cases treated with theintranasal endoscopic approach combined to the transcranial one.Their diagnostic algorithm is discussed. The surgical technique is de-scribed in details and suggestions from the senior surgeon areemphatized. Personal failures are also analyzed. Results: the successrate at the first attempt is 92% and it raises to 98.9% after the secondattempt. Follow up in all the cases reported is limited (range: 1-6years). Conclusion: whether the endoscopic repair is effective in thelong term remain to be seen. It is well validated that intranasal endo-scopic technique in the repair of CSF-leaks leaves the patient with noexternal scars. The nasal mucosa and anatomy are respected andgreat care is taken to ensure the least possible alteration to nasalphysiology. The olfactory function is preserved in the nasal cavity op-posed to the lesion side. The use of autologous grafts, preferablyfrom the nasal cavity, allows a highly compatible duraplasty. Thenautologous graft can be readily prepared from the donation area. Thehospital admission period is reduced to just several days and thepostoperative care consists of only few nasal medications.

The Role of Three Dimensional (3D)Reconstruction Imaging in the Assessment of

Posterior Ethmoid Sinus (PES)

Seung-Kyu Chung, MDDo Yeon Cho, MDSeoul, South Korea

Introduction: A complete understanding of the anatomy of si-nuses is essential in safely performing the sinus surgery. Al-though there are many reports on the anatomy of the anteriorethmoid sinus, the anatomy of PES was minimally described.Therefore, the authors tried to establish the value of 3D recon-struction imaging in the understanding of the PES anatomy.

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Methods: One mm thickness axial computed tomograms of 10patients were used as source images. Onemilimeter thickness ax-ial CT images of 10 patients were reconstructed with PC-basedsoftware (Vworks 4.0, Seoul, Korea) from DICOM files. The mid-dle turbinate, superior turbinate and lamellae in the PES werereconstructed separately and analyzed as a whole. Thepneumatizing pattern of the PES as well as the specific struc-tures, such as middle, superior & supreme turbinate, lamellaeetc. were analyzed.

Results: The anatomic structures and the pneumatization of thePES were visualized three diemensionally in many combinationsof the anatomic structures. Combining 3D anatomic structures,several patterns of pneumatization were noticed and such pat-terns were charactized by the direction of pneumatization andcompleteness of lamella structures.

Conclusions: These 3D reconstruction images were useful to un-derstand the anatomy of PES and to avoid surgical complications.

Software-enabled CT Analysis of the CarotidArtery Position and Sphenoid Sinus

Pneumatization Patterns

Pete S. Batra, MDRyan Gallivan, MD

Donald C. Lanza, MD, FACSMartin J. Citardi, MD, FACS

Cleveland, OH

Introduction: The critical relationship of the internal carotid ar-tery (ICA) with the sphenoid sinus is well recognized.High-resolution CT (HRCT) imaging in conjunction with sophis-ticated imaging software now allows for detailed analysis ofthese anatomic relationships.

Objectives: To precisely delineate the anatomic relationship be-tween the ICA and the sphenoid sinus.

Methods: Axial CT scans (1 mm slice thickness) were obtainedon a VolumeZoom CT scanner (Siemens Medical, Erlangen, Ger-many) and transferred to the CBYON Doctor Station version2.6R3FC4 (CBYON, Inc., Mountain View, CA) for review. Stan-dardized review of each CT scan using various surgical planningtools was performed.

Results: A total of 128 sides in 64 cadaveric specimens wereavailable for review. Pneumatization of the sphenoid sinus wasclassified into 4 categories: conchal, presellar, sellar, andpostsellar. The incidence of these 4 types was 4.7%, 4.7%, 25%,and 65%, respectively. The extent of sphenoid pneumatizationaround the postsellar ICA was categorized as follows: no expo-

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sure, 90 degrees, 90 to œ degrees, and 180 degrees. The inci-dence of the postsellar ICA exposure was 12.5%, 32.8%, 50%,and 1.6%, respectively. Septal insertions onto the carotid arterywere noted in 37.5% of sides and sphenoid wall dehiscences in19.5% of sides.

Conclusions: Software-enabled CT review allows for detailedstudy of the critical relationship s between sphenoidpneumatization and ICA position. Such technology can be in-valuable in surgical planning and navigation during endoscopicsinus surgery. In lieu of these findings, sinus surgeons must ex-ercise extreme caution when operating in this region to preventunintentional injury to the ICA.

Conflict details: Dr. Citardi — Member of the Cbyon scientificadvisory board.

A Comparison of Image GuidanceRegistration Methods for Endoscopic Sinus

Surgery

Stuart Hardy, MDDavid White, MDBrent Senior, MD

Chapel Hill, NC

Introduction: Stereotactic image guided technologies have pro-vided the surgeon with a means to more safely navigate throughdiseased or surgically altered sinus anatomy. Accurate registra-tion is vital to successful image guided surgery, and numerousmethods of registration have been developed in an attempt toimprove accuracy, reproducibility, and efficiency. Controversyexists as to which registration technique is best. The currentstudy used a single image guided surgery system (BrainLAB) totest the accuracy and performance of three common registrationmethods: fiducials (5 markers), anatomic landmarks (5 points),and surface registration (Z-touch(r)).

Methods: 10 cadaveric heads were scanned and underwent en-doscopic middle meatal antrostomy and sphenoidotomy. Fiveanatomic landmarks (anterior tip of the middle turbinate, poste-rior wall of the maxillary sinus, junction of the sella turcica withthe intrasinus septum, carotid artery, and optic nerve) wereidentified and marked with methylene blue dye so that the exactlocation could be accurately identified. Registration was per-formed using the above techniques, and the time required andmean registration error were recorded. Using each registrationmethod, the previously inked sites were identified and com-pared to the BrainLab CT images. The true distances betweenthe known anatomic sites and the crosshair locations on the im-ages were measured.

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Results: Statistically significant differences were noted for meanregistration error and time for registration. The mean time forregistration for the fiducial, landmark, and surface methodswere 86, 136, and 31 seconds, respectively. The mean registrationerror for the fiducial, landmark, and surface methods were 0.4mm, 2.7 mm, and 1.1 mm, respectively. When the true accuracyof the three registration methods were compared, it was foundthat fiducial registration was significantly more accurate thanboth landmark and surface registrations. Furthermore, surfaceregistration was statistically more accurate than landmark regis-tration at all anatomic sites except for the optic nerve.

Conclusions: Although all three registration methods are highlyaccurate, the fiducial method was found to be the most accurate.However, when time of registration, accuracy, andreproducibility were considered, surface registration was foundto be superior.

Conflict details: Brent Senior, one of the authors listed above,serves as a clinical consultant to the BrainLAB coorporation andaids in the research and development of improved technologies.

Endoscopic Frontal Sinus Obliteration

Raj Sindwani, MDRalph Metson, MD

Boston, MA

Introduction: Frontal sinus obliteration has traditionally uti-lized an osteoplastic flap approach. The purpose of this studywas to report on our experience with a minimally-invasive tech-nique of frontal sinus obliteration performed with endoscopicinstrumentation.

Methods: Three patients underwent endoscopic frontal sinusobliteration. Selection criteria included those with unilateralfrontal sinus disease and a small frontal sinus. After intranasalenlargement of the frontal sinus ostium, sinus mucosa was me-ticulously removed under direct endoscopic visualizationthrough both the nose and an external trephination site. The si-nus cavity was then obliterated with abdominal fat. Results werecompared to a control group of 13 patients who underwent fron-tal sinus obliteration with an osteoplastic flap approach duringthe same time period.

Results: No patients in either the study population or controlgroup required additional surgery for frontal sinus disease.There were no intraoperative complications. The endoscopicgroup had significantly less intraoperative blood loss than thecontrol group (75.0cc vs. 278.8cc, respectively, p=0.002) and ashorter operating time (2.2 hours vs. 2.9 hours, respectively,p=0.023). Mean hospital stay was also shorter in the endoscopic

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cohort (2.0 days vs. 2.8 days, p=0.002). Follow-up averaged 2.17years for the endoscopic group and 3.18 years for controls.

Conclusions: Endoscopic obliteration should be considered inpatients with a small, unilaterally diseased frontal sinus, whichhas failed previous attempts at surgical drainage. This approachappears to have reduced morbidity compared to conventionalosteoplastic flap techniques.

The Role of Nasal Airflow Testingin Nasal Surgery

Tariq Tatwani, MD, FRCSJerry S.Chapnik, MD

Toronto, Canada

Introduction: Nasal obstruction is one of the most commoncomplaints otolaryngologists deal with in clinical practice. Ob-struction is usually diagnosed by either the patient’s complaintor by the otolaryngologist’s clinical assessment. Although objec-tive nasal testing for patency was introduced over 100 years agotechnical problems have limited its use. More recently, withstandardizations of techniques and continuous calibration of theapparatus evidence supporting its use in identifying the site,and quantifying the degree of nasal obstruction and this helpsprevent unnecessary surgery.

Objectives: To determine the efficacy and feasibility ofrhinomanometry in determining the need for surgical interven-tion in patients with nasal obstruction.

Methods: Retrospective review of results of patients who hadnasal airflow testing at the Mount Sinai Hospital nasal air-flowlab in the period between January 2001 and June 30th 2002.

Results: The total number of patients who studied was 476.Forty percent were female and 60% male. Age range is (12-78)average 40.5 years. 19 had mucosal obstruction and the rest hadstructural causes. 220 patients had unremarkable results and therest had some interference with breathing. Of those with struc-tural abnormality 111 had mild obstruction, 92 had moderate ob-struction and 40 had severe nasal obstruction. Based on the nasalairflow results, 57 underwent surgery. Of these, 31 hadseptoplasty alone 21 had cryotherapy and 5 underwentseptorhinoplasty.

Conclusions: The nasal airflow testing is a valuable tool in themanagement of nasal obstruction. This study showed that only11% of patients who present with nasal obstruction requiredsome form of surgical intervention. By helping identify those pa-tients without significant structural disease unnecessary or inap-propriate surgery can be avoided.

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Endoscopic Sinus Surgery in GeriatricPopulation

Hassan H Ramadan, MDRay Van Meter, MD

Morgantown, WV

Introduction: With the baby boomer generation getting older,endoscopic sinus surgery (ESS) is being performed more on el-derly than before. We reviewed the demographics and immedi-ate complications of patients having ESS older than 65 years ofage with those of adults less than 65 years.

Methods: Review of our data base of cases who had ESS be-tween 1992 -2002 showed 568 cases who had 623 procedures.Demographics and patient characteristics of both groups was re-viewed as well as complications encountered intraoperativelyand immediately postoperatively.

Results: Forty-six (8.1%) patients were older than 65 years ofage compared to 522 patients who were 18-64 years old. 59%were males in older group compared to 45% in younger one.24% of cases were revisions in older group compared to 34% inyounger one. Complication rates were 21.7% for elderly com-pared to 12.8% for younger group. Of interest was that the com-plication rate was the highest in patients older than 65 yearswho were having revision ESS. Complication rate was the samein those having primary ESS and older than 65 and those 18-64years old having primary or revision procedure.

Conclusions: With ESS being performed more on the elderlypopulation, our results showed that those elderly who are hav-ing revision surgery are at a higher risk of complications com-pared to those having primary surgery or those younger than 65years old.

Replantation of a Near Complete AmputatedNose: Outcomes and Controversies

Mohsen Naraghi MDTehran, Iran

Objectives: Injuries to the nose may be simple or complex, withinjury involving the nasal mucosa, cartilage, bone, and skin. Theinjury may lead to subtotal or complete loss of the nose. Severalmethods have been used in reconstructing the amputated nose.We report the effectiveness of using amputated segment as acomposite graft, while reviewing the literature to discuss contro-versies in this field.

Materials and Methods: We encountered an avulsed nose seg-ment, that was composed of upper and lower lateral cartilages,

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dorsum, vestibule and skin of the nose and triangle skin seg-ments of upper lip and cheek, which was transported to our cen-ter in a plastic bag. The patient, a 27-year-old man, who wastraumatized after a blow with a broken glass, was immediatelytaken to the operating room. The skin and the mucosa were me-ticulously sutured in place. Heparin was immediately adminis-tered to the patient and medicinal leeches were appliedpostoperatively over the surface of the nose.

Results: During two weeks postoperatively, a superficial darkdiscoloration of skin progressed to form a necrotic superficiallayer over the replanted nose. On postoperative day 14, this layerfell off and beneath the live tissue was apparently visible. At thethird postoperative week, post-auricular skin was used as a fullthickness skin graft to cover the bare tissue. The amputated seg-ment survived except of a small area be over the left ala.

Conclusions: Simple careful suturing of the amputated segmentor micro-vascular techniques has been used to treat these patients.We discuss limitations and advantages of each method. It seemsthat the former has acceptable results especially when it saves theinvaluable time. After surgery, “wait and see” policy is the pre-ferred measure. The darkened skin usually indicates only partialthickness loss and the majority of the graft would survive.

Semi-Automated Digital Model ofCiliary Beat Analysis

Ashutosh Kacker, MDVishal Banthia, MD

Vijay Anand, MDNew York, NY

Background: Ciliary dysfunction is one of the main causes formucus stasis and subsequent sinusitis. Ciliary dysfunction canbe congenital or acquired. Acquired dysfunction can be due up-per respiratory infections, allergies, environmental causes or iat-rogenic causes (post-surgical or drug induced). The ability ofdiagnose Ciliary dysfunction can help tailor the treatment ofthese patients. Quantitative measurement of ciliary beat is timeconsuming and difficult task. This is an attempt to simplify themeasurement of ciliary beat.

Material and Methods: A phase contrast microscope was cou-pled with a high resolution 3-chip color camera. Images ob-tained of beating cilia at a magnification of 100X were digitizedusing Image-pro software and ciliary beat was measured usingimage analysis using a custom macro program.

Results: This technique produced a reproducible quantitativemeasurement of ciliary beat both in human volunteers as well aschicken trachea model. The digital image analysis is easier to usethan older technique of using a pin-hole photometer.

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Conclusions: The semi-automated digital model of ciliary beatanalysis provides an accurate qualitative and quantitative mea-sure of ciliary beat and can be used to evaluate effect of chemi-cals on the nasal mucosa.

Venturi Atomizer Contamination inRhinologic Practice

Marc G. Dubin, MDMaria Gergen, MD

David R. White, MDBrent A. Senior, MD

Chapel Hill, NC

Introduction: Cross contamination of venturi atomizers hasbeen reported. However, the clinical significance of these find-ings is unclear. This study quantifies the bacterial contaminationof venturi atomizers in an academic rhinology practice.

Methods: In the first study phase, atomizers were sterilized andrefilled per clinic practice with either 1% lidocaine or 0.25%tyzine (Day 0). In the second, the atomizers were wiped with70% ethanol between usage. In both phases, on days 7, 14, 21, 28,the contents of the atomizer were sprayed onto two culture me-dia. If the cultures were found to be positive, a culture from thenozzle, lumen and solution was taken and quantified.

Results: At fourteen days 34% of bottles in Phase I were culturepositive while 6% were positive in Phase II. By week four, 47%of the atomizers in Phase I, while 37% of atomizers in Phase IIwere culture positive. Furthermore, 42% of the nozzles from theatomizers with lidicaine were culture positive in Phase I, whileonly 7% where culture positive in Phase II. However, 11% of bot-tles in Phase I had a culture that grew 100 colony forming unitswhile none of the atomizers in Phase II had a significant culturequantity.

Conclusions: Over a four-week period it is equivocal whetheror not atomizers become contaminated with a clinically signifi-cant amount of bacteria as low levels can be commonly cultured.Regardless, the use of 70% ethanol wipes appears to decreasecontamination and eliminates the growth of a significant quan-tity of bacteria.

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Endoscopic Image Guided Transnasal Biopsyof the Clivus: A Case Report

Benjamin Swartout, MDRichard Lebowitz, MD

Joseph Jacobs, MDNew York, NY

Introduction: Lesions of the clivus are uncommon, and presentdiagnostic and therapeutic challenges when they occur. Whileprompt diagnosis with a tissue biopsy is a critical step in themanagement of these patients, access to the clivus is technicallydifficult and not without significant potential risks. We present acase of an endoscopic transnasal biopsy of a lesion of the clivususing stereotactic image guidance.

Methods: A 56 year old female presented with a several monthhistory of multiple cranial nerve palsies, and a lesion of theclivus detected by computed tomography. The patient under-went a transnasal endoscopic biopsy of the lesion with imageguidance. A posterior ethmoidectomy and wide spheniodotomywere performed to provide adequate exposure of the planumsphenoidale. A drill system with a cutting burr was used to bi-opsy bone marrow back to the posterior cortex of the clivus.

Results: Satisfactory exposure of the lesion was achieved. Diag-nostic biopsy specimens were obtained. There were nointraoperative complications.

Conclusions: The endoscopic transnasal approach to the clivusis a relatively noninvasive technique that allows adequate expo-sure of the clivus for biopsy while image guidance confirmsproper sampling of the radiographically abnormal tissue andhelps prevent inadvertent injury to surrounding structures.

Prevalence of Pneumatization of theSuperior Turbinate on Computerized

Tomographic Scans of the Paranasal Sinuses

Seth Kanowitz, MDRichard Lebowitz, MDAnnette Nusbaum, MD

Joseph Jacobs, MDNew York, NY

With the availability of high resolution computerizedtomographic (CT) scanning, and the acceptance of the functionaltheory of chronic rhinosinusitis, a great deal of attention hasbeen paid to the bony and mucosal anatomy of the paranasal si-nuses. It has been well documented that structural anatomic ab-

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normalities, such as pneumatization of the middle turbinate, cancontribute to the development of sinusitis through blockage ofthe normal sinus drainage pathways. Much of the literature hasbeen focused on the ostiomeatal complex and its relation tochronic rhinosinusitis (CRS), with little discussion of the supe-rior turbiante and its possible relation to sinus and nasal disease.The role of mucosal contact points, due to pneumatization of thesuperior turbinate, in the pathophysiology of headaches hasbeen reported. However, the incidence of the radiographic find-ing of pneumatization of the superior turbinate has not been de-scribed in the literature. We reviewed the coronal paranasalsinus CT scans of 50 consecutive patients (100 sides) referred toour Rhinology division with symptoms of CRS, to determine theincidence of pneumatization of the superior turbinates. The totalincidence was determined to be 20%, with bilateralpneumatization approximately equal to unilateralpneumatization. Potential implications of this finding in patientswith sinus and nasal symptoms are discussed.

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NOTES

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NOTES

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MEMBER LIST

Walter J. Aagesenz, MD, San Jose, CARobert F. Aarstad, MD, Shreveport, LAAwny A. Abdou, MD, Johnson City, NYTom Abelson, MD, Beachwood, OHDavid A. Abraham, MD, Thief River Falls, MNManoj T. Abraham, MD, New York, NYMark J. Abrams, MD, Rock Hill, NCRavi Agarwal, MD, Glendale, AZMehdi Ahmadi, MD, Tehran, IranRobert A Akins, MD, Sioux Falls, SDMouwafak Muflih Al-Rawi, MD, Philadelphia, PANabil Al-Zaher, MD, United Arab EmiratesPaul Alberti, MD, North Haven, CTKeith J Alexander, MD, Lexington, KYGeorge Alexiades, MD, New York, NYGary Allan, MD, South Africa 2041Joseph Allegretti, MD, Chicago, ILPhillip G Allen, MD, Albany, GAEurico Almeida, MD, PortugalWiliam Alsup, MD, Winston Salem, NCRonald Alvarez, MD, Cherry Hill, NJBryan Ambro, MD, Philadelphia, PARonald Amedee, MD, New Orleans, LAManali S. Amin, MD, Omaha, NEVijay Anand, MD, New York, NYVinod Anand, MD, Jackson, MSJ. Noble Anderson, Jr., MD, Montgomery, ALThomas Andrews, MD, Saint Petersburg, FLJennifer Ankerstjern, MDFrank Anning, MD, AustraliaJack B. Anon, MD, Erie, PAJoel Anthis, MD, Katy, TXNancy Appelblatt, MD, Sacramento, CAPierre G. Arbour, MD, Boynton Beach, FLSanford Archer, MD, Lexington, KYRichard Arden, MD, Sterling Heights, MIJoseph Ardito, MD, Havertown, PAHarold Arlen, MD, South Plainfield, NJDavid C. Armstrong, MD, Johnstown, PAMichael Armstrong, MD, Richmond, VANorman Armstrong, DO, Piqua, OHBenjamin Asher, MD, Berlin, VTJoseph Atkins, MD, Philadelphia, PAMitchell Austin, MD, Evans, GAMitchell B. Austin, MD, Evans, GAMichael Avidano, MD, Stockbridge, GABabak Azizzadeh, MD, Boston, MA

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H. Clifford Baggett, MD, Rocky Mount, NCSean Bailey, MD, Saint Louis, MOLeslie L Baker, MD, Knoxville, TNPhillip Ballinger, MD, Searcy, ARJames C Banich, MD, Maywood, ILStephen Bansberg, MD, Scottsdale, AZPat Barelli, MD, Leawood, KSDarryk W. Barlow, MD, Yakima, WAGerald Bart, MD.,FACS, Wichita, KSSteven W. Barthel, MD, Cleveland, OhPhillip Bartlett, MD, San Francisco, CAJames Barton, MD, Milwaukee, WIMark R. Bassett, MD, Spokane, WABenjamin Bassichis, MD, Dallas, TXEvan Bates, MD, Dallas, TXRami Batniji, MD, Albany, NYPete Batra, MD, Chicago, ILWilliam Bauer, MD, Newnan, GAEric Baum, MD, Philadelphia, PAMary Beauchamp, MD, Maywood, ILDaniel Becker, MD, Philadelphia, PAErnest Behnke, MD, Ashland, KYAnn Bell, MD, Waterloo, IAWilliam Belles, MD PC, Buffalo, NYCarlos Benavides, MD, Manchester, CTThomas Benda, Jr., MD, Dubuque, IAErica Bennett, MD, Los Angeles, CAMichael Benninger, MD, Detroit, MIJohn Bent, MD, New York, NYLawrence Berg, MD, Elgin, ILJennifer K. Berge, MD, Pheonix, AZLeslie Berghash, MD, Port Saint Lucie, FLRichard T. Bergstrom, MD, Shaker, OhGerald Berke, MD, Los Angeles, CAManuel Bernal-Sprekelsen, MD, Barcelona, SpainJoel M Bernstein, MD, Getzville, NYJoseph M Bernstein, MD, New York, NYPhilip Bernstein, MD, Sacramento, CABill W. Berry, Jr., MD, Virginia Beach, VAShelley R Berson, MD, Bardonia, NYMichael Bertino, MD, San Antonio, TXBernard Bertrand, MD, BelgiumDavid W. Best, MD, Milwaukee, WIDavid J. Beste, MD, Milwaukee, WIMathew Beyer, MD, Ridgeland, MSNikhil Bhatt, MD, Elgin, ILAbir Bhattacharya, MD, United KingdomNeil Bhattacharyya, MD, Boston, MARajendra Bhayami, MD, New York, NY

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John Biedlingmaier, MD, Baltimore, MDWilliam Biggers, MD, FACS, Chapel Hill, NCRichard D. Blair, MD, Pittsburgh, PAAndrew Blank, MD, Bayside, NYStanley M. Blaugrund, MD, New York, NYAndrew Blitzer, MD, New York, NYJeffrey Block, MD, Green Bay, WICharles Bluestone, MD, Pittsburgh, PADavid Bradley Bobbitt, MD, Cincinnati, OHBrian Bodish, MD, Birmingham, ALPeter Boesen, MD, Des Moines, IAAnn Bogard, MD, Winston Salem, NCRodolfo Bolanos, MD, Miami, FLWilliam Bolger, MD, FACS, Bethesda, MDRobert E. Bonham, MD, Dallas, TXJames Boozan, MD, Trenton, NJGeorge Boris, MD, Culver City, CAT. Borski, MD, Houston, TXJoseph Houston Bosley, MD, Shreveport, LARobert Boucher, MD, Winchester, VAMichiel Bove, MD, Bronx, NYV. Richard Bowen, MD, Omaha, NEDavid Bowling, MD, Stoneham, MAJohn Boyajian, MD, Boise, IDCharles Boyd, MD, Ann Arbor, MIHolly Christine Boyer, MD, Minneapolis, MNTimothy R. Boyle, MD, Marshfield, WIEdward Brandow, Jr., MD, Albany, NYRebecca Brandsted, MD, St. Louis, MOCheryl Braud, MD, Baton Rouge, LAJ. George Braun, MD, New York, NYJack Breaux, Jr., MD, Baton Rouge, LAAmy C. Brenski, MD, Dallas, TXRobert Bridge, MD, Phoenix, AZRussell Deane Briggs, MD, Galveston, TXWilliam Briggs, MD, Arlington, TXPaul Brindley, MD, Houston, TXJeffrey E. Brink, MD, Jacksonville Beach, FLKenneth Briskin, MD, Chester, PAJohn Brockenbrough, MD, Maywood, ILBrian Brodish, MD, Winterville, NCBrian Broker, MD, Narbeth, PALaura Brown, MD, Birmingham, ALOrval E. Brown, MD, Dallas, TXMichael Bryan, MD, Webster, TXJames Bryant, MD, Hermitage, TNGrady L. Bryant, Jr., MD, Hermitage, TNSteven Buck, MD, Buffalo, NYEdward D Buckingham, MD, Galveston, TX

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Brad Buell, MD, Bismarck, NDJohn Buenting, MD, Raleigh, NCDuc Bui, MD, Westminster, CARobert Bumsted, MD, Chicago, ILAlan Burke, MD, Portland, ORJames Burns, MD, Centerville, OHNicolas Busaba, MD, Boston, MARichard Busch, MD, Bakersfield, CAJose Busquets, MD, San Juan, PRHenry Frederick Butehorn, III, MD, Albany, NYAllen Butler, MD, Augusta, GASydney Butts, MD, Bronx, NYGary Buxa, MD, Bellaire, TXBenjamin Cable, MD, Wheaton, MDOzcan Cakmak, MD, Ankara, TurkeyThomas Calcaterra, MD, Los Angeles, CADavid Caldarelli, MD, Chicago, ILKaren Calhoun, MD, Galveston, TXHerbert Camp, MD, Midland, MIAndrew Campbell, MD, Sheboygan, WIJeffrey Campbell, MD, Lexington, KYJohn Campbell, MD, Tulsa, OKWinston Campbell, MD, Nassua, BaC. Ron Cannon, MD, Flowood, MSStanley Cannon, MD, Miami, FLHarry Cantrell, MD, Camden, NJDwayne T. Capper, MD, Iowa City, IAHenry Carder, MD, Dallas, TXJohn Carew, MD, New York, NYA. Simon Carney, Dr., South AustraliaDaniel G. Carothers, MD, Chicago, ILRichard Carter, MD, Greenwood, SCGerard Carvalho, MD, Redwood City, CAPeter Casano, MD, Jackson, MSRoy Casiano, MD, Miami, FLPaolo Castelnuovo, MD, ItalyPeter Joseph Catalano, MD, FACS, Burlington, MARobert Cater, MD, Meridian, MSJon Chadwell, MD, Cincinnati, OHStephen J. Chadwick, MD, Decatur, ILFayez Chahfe, MD, Utica, NYStephen W. Chandler, MD, Morgantown, WVRakesh Chandra, MD, Chicago, ILBinoy Chandy, MD, Shreveport, LAKristi Chang, MD, Toluca Lake, CAJerry Chapnik, MD, CanadaClive Anthony Chappel, MD, AustraliaDaniel Charous, MD, Philadelphia, PABradley J. Chastant, MD, Lafayette, LA

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Rashid Chaudhry, MD, Brooklyn, NYWenfu Chen, MD, Chillicothe, OHAlexander Chester, MD, Washington, DCScott Chiang, MD, Los Angeles, CAAlexander Chiu, MD, Stanford, CAJames Chmiel, MD, Buffalo, NYMichael Cho, MD, San Francisco, CAKyle Choe, MD, New York, NYJames Chow, MD, Maywood, ILDewey Christmas, Jr., MD, Daytona Beach, FLSeung-Kyu Chung, MDSung J Chung, MD, Cincinnati, OHChristopher Church, MD, Loma Linda, CARobert Cihak, MD, Aberdeen, SDMartin J. Citardi, MD, Cleveland, OHCharles Clark, III, MD, Durham, NCJames Clemens, MD, Green Bay, WIDean Clerico, MD, Kingston, PALanny Close, MD, New York, NYHarvey Coates, MD, AustraliaWilliam Cobb, MD, Plano, TXD. Thane Cody, II, MD, Keokuk, IAJoel Cohen, MD, Scottsdale, AZNoam Cohen, MD, Philadelphia, PARandall Cohen, MD, Tuscon, AZRicardo Sergio Cohen, MD, ArgentinaBurton Cohn, MD, Camp Hill, PAJack Coleman, MD, Nashvill, TNC. Michael Collins, MD, Cincinnati, OHJ. Robert Coltharp, Jr., MD, Hattiesburg, MSDavid B Conley, MD, Chicago, ILSteven Connelly, MD, Saint Louis Park, MNJames Connolly, MD, Jackson, MSPaul Cook, MD, Columbia, MOTed Cook, MD, Portland, ORJacquelynne Corey, MD, Chicago, ILRachel Cormier, MD, Geneva, NYAnthony J Cornetta, MD, Philadelphia, PAAlejandro J. Correa, MD, Nashville, TNMatthew Cosenza, MD, Chillicothe, OHPeter D. Costantino, MD, New York, NYSteven Coutras, MD, Cumberland, MDRichard T. Crane, MD, Eau Claire, WIMichael Crawford, MD PC, Council Bluffs, IAWilliam Crawford, MD, Oshkosh, WIDaniel Crofton, MD, Oneida, NYRoger Crumley, MD, Orange, CAMichael Cruz, MD, Spokane, WACarlos Cuilty-Siller, MD, Laredo, TX

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Michelle Marie Cullen, MD, Duluth, GAMichelle Cummins, MD, Port Lavca, TXJason Cundiff, MD, Chicago, ILDevin M. Cunning, MD, Lake Havasu City, AZArthur Curtis, MD, Chicago, ILKamal Daghistani, MD, Saudi ArabiaLinda Dahl, MD, Bronx, NYKim L. Dakin, MD, Opelousas, LAThomas Dalsasso, Jr., MD, Colorado Springs, COAngela Damiano, MD, West Harrison, NYMyra Danish, MD, Troy, MILawrence Danna, MD, West Monroe, LATerence Davidson, MD, San Diego, CAR. Alan Davis, MD, Bristol, TNSpiros Davris, MD, GreeceDouglas Dawson, MD, Muscatine, IAGeorge S Dawson, MD, Morgantown, WVRichard Dawson, MD, Oklahoma City, OKLarry H. Day, MD, Hattiesburg, MSGustavo De Hostoss, MD, CanadaRichard De Persio, MD, Knoxville, TNThomas De Tar, MD, Post Falls, IDRichard De Vore, MD, Cincinnati, OHMichael Decherd, MD, Dallas, TXDaniel A. Deems, MD, PhD, Sarasota, FLJohn Del Gaudio, MD, Atlanta, GALeopoldo E. Delucca, MD, Fort Dodge, IAMunir Demirci, MD, TurkeyDavid Denman, MD, Omaha, NERichard J Depersio, MD, Knoxville, TNMartin Desrosiers, MD, CanadaElimeleh Deutsch, MD, IsraelMark Deutsch, MD, Cincinnati, OHMichael DeVito, MD, Albany, NYPaul Di Biasse, MD, Steubenville, OHWilliam Dickey, MD, Chicago, ILE. Nicholas Digges, MD, Omaha, NEDavid A. Dillard, MD, Atlanta, GAMike Dillard, MD, Morristown, TNDavid Dinges, MD, Dalton, GAHamilton Dixon, MD, Rome, GAHamid Djalilian, MD, Minneapolis, MNPeter Doble, MD, Twin Falls, IDThomas Dobleman, MD, Omaha, NETimothy D. Doerr, MD, Rochester, NYJoni Kristin Doherty, MD, Topanga, CAPaul Donald, MD, Sacramento, CADavid Donaldson, MD, Buffalo, NYAlexander Donath, MD, St. Louis, MO

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James Donegan, MD, Lebanon, NHPaul Drago, MD, Rock Hill, SCPeter Driscoll, MD, Manhattan Beach, CANorman Druck, MD, Chesterfield, MOGlenn Drumheller, DO, Everett, WALarry Duberstein, MD, Memphis, TNJames Dudley, MD, San Fransisco, CABrian Duff, MD, Providence, RIWallace Duff, MD, Omaha, NEWilson Dumornay, MD, Bronx, NYThane Duncan, MD, Cordova, TnJames Duncavage, MD, Nashville, TNRobert Dunn, MD, Orange, CABlanca I. Durand, MD, Atlanta, GADory Durr, MD, Outremont, Quebec, CanadaJay Dutton, MD, Chicago, ILAndrew Dzul, MD, St. Clair Shores, MIWilliam Earnshaw, MD, AustraliaDavid Edelstein, MD, New York, NYRobert Ehrhard, MD, Denver, COJohn E. Eisenbeis, MD, Saint Louis, MOLee Eisenberg, MD, Englewood, NJDavid Eisenman, MD, Silver Spring, MDImad El-Hayderi, MD, BelgiumE.Scott Elledge, MD, Birmingham, ALFrank Elsworth, MD, AustraliaSamy S. Elwany, MD, EgyptAfshin J. Emani, MD, Tuscon, AZIvor A. Emanuel, MD, San Francisco, CAPrecha Emko, MD, Syracuse, NYGerald English, MD, Englewood, COMoshe Ephrat, MD, New Hyde Park, NYEmily E. Epstein, MD, St. Louis, MOMark Erlich, MD, New York, NYJoel Ernster, MD, Colorado Springs, CORaphael Espinosa, MD, MexicoKarin Evan, MD, Minneapolis, MNPaul Evangelisti, MD, Rome, GAGeorge Facer, MD, Scottsdale, AZMichelle Lee Facer, MD, Rochester, MNDavid Fairbanks, MD, Bethesda, MDNizar Fakeeh, MD, Saudi ArabiaAkram Farag, MD, Mansfield, OHRobert Faries, MD, Torrance, CAHoward S. Farmer, MD, Princeton, NJPatrick C. Farrell, MD, Omaha, NEKenneth H. Farrell, II, MD, Fort Lauderdale, FLGeorge Farrell, III, MD, Hobbs, NMRussell Faust, MD, Detroit, MI

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Gary Feinberg, MD, Riverside, CABruce Feldman, MD, Chevy Chase, MDDouglas Feldman, MD, Washington, DCJeffrey Fenwick, MD, Charleston, SCBerrylin Ferguson, MD, Pittsburgh, PARobert Fieldman, MD, West Orange, NJSamuel Fisher, MD, Durham, NCRobert A. Fishman, MD, St. Clair Shores, MIPhillip B. Flexon, MD, Savannah, GALawrence J. Fliegelman, MD, New York, NYKaren J. Fong, MD, Portland, ORRay Fontenot, Jr., MD, Beaumont, TXRick A. Fornelli, MD, Fairview, PAMark L. Fox, MD, Scarsdale, NYMichael D. Franklin, MD, Topeka, KSStephen Freifeld, MD, Springfield, NJSaul Frenkiel, MD, CanadaMarvin P. Fried, MD, Bronx, NYMichael Friedman, MD, Chicago, ILOren Friedman, MD, Philadelphia, PAWilliam Friedman, MD, Saint Louis, MOMichael A. Fritz, MD, Cleveland, OhStephen Froman, MD, Coraopolis, PABeverly Fulcher, MD, Jackson, MSEdward Gabalski, MD, Plainview, NYRobert Gadlage, MD, Duluth, GAChad Galer, MD, Omaha, NESuzanne K Galli, MD, New York, NYRyan Gallivan, MD, Cleveland, OHEmil Ganjian, MD, Greatneck, NYAndrew R. Ganz, MD, New York, NYTierry Garcia, MD, Indianapolis, INCourtney West Garrett, MD, Chicago, ILRalph Gaskins, MD, Atlanta, GARebecca Gaughan, MD, Olathe, KSJames Gaul, MD, Salisbury, MDJohn Gavin, MD, Albany, NYIrwin Gaynon, MD, Whitefish Bay, WIClarence Gehris, MD, Witherville, MDKenneth Geller, MD, Los Angeles, CAHoward Gelman, MD, Annapolis, MDElaina George, MD, Atlanta, GAMark E. Gerber, MD, Chicago, IlRoland Gerencer, MD, Albequerque, NMFranklyn Gergits, MD, Berwick, PAJohn Gerwin, MD, Birmingham, ALNathan A. Geurkink, MD, Lebanon, NHRandal B Gibb, MD, Payson, UTScott R. Gibbs, MD, Huntington, WV

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Michael Gilbert, MD, Salt Lake City, UTMatthew Don Gillihan, MD, Buffalo, NePaul Gittelman, MD, Mamroneck, NYAlvin Glasgold, MD, Highland Park, NJRichard Gliklich, MD, Boston, MAJames Go, MD, Key West, FLPaulino E. Goco, MD, Murfreesboro, TNEmilio Godoy, MD, Arica, ChileBradley E. Goff, MD, Cartersville, GAJay H. Goland, MD, Bakersfield, CAScott Gold, MD, New York, NYSteven M. Gold, MD, Englewood, NJAndrew Goldberg, MD, San Francisco, CASeth M. Goldberg, MD, Rockville, MDMichael Goldman, MD, Chicago, ILNeal Goldman, MD, Winston-Salem, NCSteven Goldman, MD, Beachwood, OHMichael Goldrich, MD, East Brunswick, NJEarl Golightly, MD, Griffin, GAOmar A. Gonzales-Yanes, MD, Puerto RicoGarth Good, MD, York, PARichard L. Goode, MD, Palo Alto, CARoy Goodman, MD, White Lake, MIM. Alan Goodson, MD, Birmingham, ALRichard Goodwin, MD, Bradenton, FLStephen D Goodwin, MD, Gretna, LAHarsha Gopal, MD, Boston, MAQuinton Gopen, MD, Los Angeles, CAAndrew Gordon, MD, New ZealandJan Gosepath, MD, GermanyBenoit Gosselin, MD, Lebanon, NHJoshua Gottschall, MD, Detroit, MIJon Graham, MD, South Miami, FLScott Graham, MD, Iowa City, IARobinson Granados, MD, Barranquilla, COJoachim Granzow, MD, Los Angeles, CABernard Green, MD, Boynton Beach, FLDavid Greene, MD, Naples, FLChristopher W. Greer, MD, Bossier City, LAJohn Griffin, MD, Macon, GAFelicia J Grisham, MD, Edmond, OKCharles W. Gross, MD, Charlottesville, VANeil D. Gross, MD, Portland, ORWilliam Gross, MD, Cordova, TNHarold Groves, DO, Eugene, OREdgar Guerra, MD, 06470 MexicoPaul Guggenheim, MD, Ben Lomond, CATu Gui-Yi, MD, Bejing ChinaKaminszizik Guillermo, MD, Argentina

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Barbara Guillette, MD, Cranston, RIPatrick Gullane, MD, Toronto, ONAnil Gungor, MD, Pittsburgh, PAAkash Gupta, MD, Cincinnati, OHSanjay Gupta, MD, Angola, INRay O. Gustafson, MD, Rochester, MNJose Gutierrez-Marcos, MD, MexicoRonald M. Guy, MD, FACS, Broken Arrow, OKNorman Haacke, MD, United KingdomJames A Hadley, MD, Rochester, NYIshrat Hakim, MD, Highland, INDavid Halvorson, MD, Alabaster, ALRonda Hamaker, MD, Indianapolis, INFiras Hamdan, MD, Perry, FLMark Hamilton, MD, Indianapolis, INAvraham Hampel, MD, Elkins Park, PAChris Hampson, MD, Maywood, ILJoseph Han, MD, Portland, ORSteven Handler, MD, Philadelphia, PAGady Har-El, MD, Hollis, NYScott Hardeman, MD, St. Louis, MOMoshe Harell, MD, IsraelWilliam Harmand, MD, Syracuse, NYWillard C. Harrill, MD, Hickory, NCKevin C. Harris, MD, Milwaukee, WIMonte O. Harris, MD, Silverspring, MDScott Edwin Harrison, MD, Jackson, MSFrancis Hart, MD, Grand Rapids, MIHathaway E Harvey, MD, Chattanooga, TNMakoto Hasegawa, MD, Tokyo, JapanKaren Haunss-Sapinski, MD, Great Neck, NYRichard Haydon, III, MD, Lexington, KYH. Hearnsberger, III, MD, Little Rock, ARRichard L. Hebert, II, MD, Eunice, LARyan Heffelfinger, MD, Philadelphia, PASadru Hemani, MD, Newburyport, MAArthur Hengerer, MD, Rochester, NYDavid Henick, MD, Fort Lee, NJEdward Hepworth, MD, Albuquerque, NMBrian Herr, MD, Maywood, ILAlfredo Herrera, MD, ColumbiaEugene Hesdorffer, MD, Jackson, MSSabine V. Hesse, MD, Ridgeland, MSJulius Hicks, MD, Birmingham, ALHau Hien, MD, VietnamDaniel Hinckley, MD, Idaho Falls, IDKen-ich Hisamatsu, MD, Tokyo, JapanKhanh-Gien Hoang, MD, Charleston, SCDenis Hoasjoe, MD, Baytown, TX

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Sanford Hoffman, MD, Buffalo, NYEric H. Holbrook, MD, Omaha, NEJ. David Holcomb, MD, Sarasota, FLWilliam Holmes, MD, Fairmont, MNNorman Holzberg, MD, West Orange, NJSeok-Chan Hong, MD, South KoreaRichard Hood, MD, Palmyra, VACarl T. Hook, MD, FACS, Norman, OKHunter Hoover, MD, Charlott, NCLarry Hoover, MD, Kansas City, KSJeremy Hornibrook, MD, New ZealandJohn Houck, MD, Oklahoma City, OKSteven M. Houser, MD, Cleveland, OHSean Houston, MD, Wilmington, DERaymond Howard, MD, Brooklyn, NYMark Howell, MD, Johnson City, TNMark J. Hoy, MD, Mt. Pleasant, SCBruce Hudkins, MD, Tulsa, OKScott Huebsch, MD, Ames, IAJames Huerter, MD, Omaha, NEKenneth Hughes, MD, Lexington, KYKevin J Hulett, MD, Maywood, ILDarrell Hunsaker, MD, San Diego, CAShannon Elizabeth Hunter, MD, Durham, NCSteve Hunyadi, Jr, MD, Independence, OHJerry Huo, MD, Scarsdale, NYMichael K. Hurst, MD, Morgantown, WVKeith Hurvitz, MD, Los Angeles, CAJoseph Hutchison, MD, Troy, NYPeter H. Hwang, MD, Portland, ORAhamefule Olu Ibekwe, MD, Saudi ArabiaHanil Ibrahim, MD, Oak Park, ILTasca Igmazio, MD, ItalyEl Hayderi Imad, MD, Liege Belgium 4031Donald Ingram, MD, Festus, MOMasatuki Inouye, MD, Stanford, CASteven F. Isenberg, MD, Indianapolis, INWilliam David Isenhower, MD, Greenwood, SCStacey Lynn Ishman, MD, Milwaukee, WISteven Issenberg, MD, Lewisburg, WVSera Jacob, MD, Greensboro, NCOfer Jacobowitz, MD, New York, NYIan N. Jacobs, MD, Philadelphia, PAJoseph Jacobs, MD, New York, NYRobert Jacobs, MD, Oceanside, CAAbdullmohsin Jafar, MD, KuwaitBruce Jafek, MD, Denver, CODavid Jakobowicz, MD, Bronx, NYTarek Jamal, MD, Saudi Arabia

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Amin R. Javer, MD, Vancouver, BCJohn A. Jebeles, MD, Birmingham, ALRong-San Jiang, MD, Taiwan (ROC)Hong-Ryul Jin, MD, Cheongju,South KoreaJohn Jiu, MD, Jonesboro, ARStephanie Joe, MD, Chicago, ILJonas Johnson, MD, Pittsburgh, PAKenneth Johnson, MD, Birmingham, ALPerry Johnson, MD, Omaha, NETerence Johnson, MD, San Diego, CAPaul Jones, MD, Chicago, ILGerald Joseph, MD, Baton Rouge, LAJordan Josephson, MD, New York, NYCharles Juarbe, MD, Bayamon, PRSlobodan Jugo, MD, Greenville, KYErik Kaas, MD, Boston, MADavid Kaba, MD, Williston, NDAshutosh Kacker, MD, New York, NYZoheir J. Kaiser, MD (regular), South Hill, VAJohn Kalafsky, MD, Norfolk, VAJames Kallman, MD, Philadelphia, PAShashi Kaluskar, MD, N. Ireland, UKCharles Kaluza, DO, Portland, ORGuillermo Kaminszczik, MD, ArgentinaMadan N. Kandula, MD, Oklahoma City, OKSeth Kanowitz, MD, New York, NYSanjay Kantu, MD, Flushing, NYBrian A. Kaplan, MD, Charlottesville, VAIvan Karabachev, MD, Las Vegas, NVFrank L. Kardos, MD, Wayne, NJAndrew Karpenko, MD, Detroit, MIJan L. Kasperbauer, MD, Rochester, MNEdward Kass, MD, Waukesha, WIMatthew Kates, MD, New Rochelle, NYGeorge Katsantonis, MD, St. Louis, MOAlvin Katz, MD, New York, NYHarry Katz, MD, Midland Park, NJLawrence Kaufman, MD, Albany, NYScott Kay, MD, Princeton, NJSrinivas Kaza, MD, Danville, PAKen Kazahaya, MD, Philadelphia, PASavuas Kazanas, MD, Athens, GreeceHerbert Kean, MD, Philadelphia, PAJohn Keebler, MD, Mobile, ALDaniel R. Keech, MD, Athens, TXStephen M Kelanic, MD, Chicago, ILMichael Kelleher, MD, Salisbury, MDMark L. Keller, MD, Omaha, NERobert M. Kellman, MD, Syracuse, NY

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Bryan Kemker, MD, Oak Park, ILDavid Kennedy, MD, Philadelphia, PAEugene Kern, MD, Coconut Creek, FLRobert Kern, MD, Chicago, ILJeffrey Kerner, MD, Lake Sucess, NYMarc Kerner, MD, Northridge, CAMumtaz Khan, MD, Nashville, TNChandra Khasgiwala, MD, Lowell, MAUmang Khetarpal, MD, Bay City, MIAssad Khoury, MD, Washington, NYThomas Kidder, MD, Milwaukee, WIMatthew Kienstra, MD, Tampa, FLJohn D. Kilde, MD, Milwaukee, WIEugene Kim, MD, San Francisco, CAEugene J. Kim, MD, San Francisco, CAEun-Seo Kim, MD, South KoreaJean Kim, MD, Baltimore, MDSeon Kim, MD, Inchon City, KoreaSeungwon Kim, MD, Syracuse, NYSihun Alex Kim, MD, Detroit, MISuk-Chun Kim, MD, Sungnam, Kyonggi-do, KoreaCharles Kimmelman, MD, New York, NYRobert E King, MD, Maywood, ILJames King, Jr., MD, Galax, VATodd Kingdom, MD, Denver, CORonald Kirkland, MD, Jackson, TNJeffrey Kirsch, MD, Conway, ARMilind. Kirtane, MD, Maharashtr, IndiaRussell Kitch, MD, Charleston, SCGeorge G. Kitchens, MD, Montgomery, ALFrederick Klippert, MD, Augusta, GAJ Michael Klossek, MD, FranceDarrell Klotz, MD, Rochester, NYJoost L Knops, MD, Bellingham, WAMichael Knowland, MD, Portland, MERobert Knox, MD, Louisville, KYRobert Komorn, MD, Houston, TXCharles Koopmann, Jr., MD, Ann Arbor, MIJodi M. Kornak, MD, Omaha, NEMichael Kortbus, MD, New York, NYStilianos Kountakis, MD, PhD, Charlottesville, VAKeith Kowal, MD, Riverdale, GADonna Kozee, MD, Augusta, GADennis Kraus, MD, New York, NYHelen Krause, MD, Pittsburgh, PAJeffrey Krivit, MD, Cedar Rapids, IAJohn Krouse, MD, PhD, Detroit, MIFrederick Kuhn, MD, Savannah, GAVandana Kumra, MD, New York, NY

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Stephen B. Kupferberg, MD, Silver Springs, MDChristina J Laane, MD, San Francisco, CAAnthony N. LaBruna, MD, New York, NYAmy Lai, MD, Toppsfield, MADaniel Lai, MD, Jamestown, NYSteven Landau, MD, Martinsville, VAMartin I. Lander, MD, IsraelGary P Landrigan, MD, Burlington, VTRoee Landsberg, MD, IsraelAndrew Lane, MD, Baltimore, MDCharles Lane, Jr., MD, Fort Smith, ARDonald C. Lanza, MD, Cleveland, OHJohn T. Lanza, MD, Port Saint Lucie, FLPaul E. Lapco, MD, Pittsburgh, PABabak Larian, MD, Los Angeles, CAChristopher Larsen, MD, Kansas City, KSArthur M. Lauretano, MD, Chelmsford, MAWilliam Lavelle, MD, Worcester, MADonald Lawrence, MD, Kansas City, MOWilliam Lawson, MD, DDS, New York, NYAmy D. Lazar, MD, Summerville, NJBryan Leatherman, MD, Hattiesburg, MSMark D. Lebeda, MD, East Lansing, MIJeffrey LeBenger, MD, Summit, NJRobert Lebovics, MD, New York, NYRichard Lebowitz, MD, New York, NYDaniel Lee, MD, Los Angeles, CADennis Lee, MD, MPH, Bloomington, ILDerek Lee, MDEdward Lee, MD, San Marino, CAKelvin Lee, MD, New York, NYMing-Ju Lee, MD, ChinaPhillip Lee, MD, Mason City, IASherrod Lee, MD, Peru, ILSu Lee Towson, MDR. R. Leinhardt, MD, New York, NYDonald Leopold, MD, FACS, Omaha, NERaymond Lesser, MD, Ardmore, PAHoward L. Levine, MD, Cleveland, OHJonathan M Levine, MD, Philadelphia, PAMeron Levitats, MD, Lighthouse Point, FLWilliam Lewis, MD, Sarasota, FLGreg R. Licameli, MD, Boston, MABenjamin Light, MD, Pittsburgh, PAJon Liland, MD, Worcester, MAJessica Lim, MD, Brooklyn, NYJin Lim, MD, Richmond, VAKaren Lin, MD, New York, NYJonathan Lindman, MD, AL

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Dana T. Link, MD, Rochester, MNPamela Lipkin, MD, New York, NYRobert G. Lisk, MD, Ellicott City, MDDavid A Litman, MD, Philadelphia, PAJohn Little, MD, Knoxville, TNEdmund Liu, MD, New York, NYPhilip Liu, MD, Honesdale, PADo Huu Loc, MD, VietnamDrew Locandro, MD, Marietta, GAW. E. Loch, MD, Lutherville, MDW. K. Locklin, MD, Kalamazoo, MITodd A. Loehrl, MD, Wauwatosa, WINeal Lofchy, MD, Chicago, ILLloyd Loft, MD, New York, NYChristopher Lolachi, MD, Ranchos Palos Verdes, CADeborah Loney, MD, Ashburn, VAFausto-Infante Lopez, MD, MexicoManuel Lopez, MD, Cincinnati, OHRobert Lorenz, MD, Cleveland, OHMark C. Loury, MD, Ft. Collins, CORay J. Lousteau, MD, New Orleans, LATrent Lowery, MD, Homeland, ALFrank Lucente, MD, Brooklyn, NYValerie Lund, MD, United KingdomRodney Lusk, MD, Fort Collins, CORichard Mabry, MD, Duncanville, TXBrian Machida, MD, West Covince, CADino Madonna, MD, Leesburg, FLWalter Maimon, MD, Dayton, OHKenneth Mak, MD, Los Angeles, CAKiyoshi Makiyama, MD, 101-8309 JapanBruce T. Malenbaum, MD, Durham, NCHussain Malik, MD, East Stroudsburg, PAWilliam Mancoll, MD, Hartford, CTAditi Mandpe, MD, San Fransisco, CAAnthony Maniglia, MD, Cleveland, OHJeffrey Manlove, MD, St. Paul, MNCharles H. Mann, MD, Cary, NCWolf Mann, MD, Mainz, GermanyScott Manning, MD, Seattle, WABelinda Mantle, MD, Birmingham, ALAlex Marban, MD, Hoover, ALLouis Mariotti, MD, Lakeville, PASteven Marks, MD, Bel Air, MDBradley F Marple, MD, Dallas, TXDarby Marshall, MD, Gainesville, ILRobert Marshall, MD, Bakersfield, CAJean Marti, MD, SwitzerlandPaul Martin, MD, Loma Linda, CA

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Pierre Martin, MD, Cortland, NYRichard A Martin, MD, Cape Girardeau, MOJohn Mason, MD, Charlottesville, VABrian L. Matthews, MD, Winston-Salem, NCKenneth Mattucci, MD, Manhasset, NYPeter F Maurice, MD, Washington, DCThomas McCaffrey, MD, Tampa, FLClement McDonald, MD, Indianapolis, INRobert McDonald, MD, Jefferson City, MOThomas McDonald, MD, Rochester, MNMariann McElwain, MD, Pittsburgh, PAEdith McFadden, MD, Milwaukee, WIGuy McFarland, MD, Iowa City, IAMichael A. McGee, MD, Benton, AZJames C. McGhee, MD, Marion, ILRobert McGrew, MD, Little Rock, ARW. Frederick McGuirt, Sr., MD, Winston-Salem, NCJames Wesley McIlwaine, MD, St. Louis, MOLee Ann McLaughlin, MD, New York, NYRobert McLaughlin, MD, Philadelphia, PAF. Anthony McLeod, MD, Alexander City, ALJohn McMahan, MD, Chicago, ILSean M McWilliams, MD, Birmingham, ALCem Meco, MD, AustriaNeelesh Mehendale, MD, Dallas, TXMark Mehle, MD, Lakewood, OHDinesh Mehta, MD, Bronx, NYJeremy Melker, MD, Gainsville, FLJonathan Mellema, MD, Cincinnati, OHGeorge A. Melnik, MD, Farmington, CTOleg Merculov, MD, RussiaRobert Merrell, Jr., MD, Daytona Beach, FLRobert Merritt, MD, Winter Haven, Fl.W. Davis Merritt, MD, Boise, IDJanet Mertz, MD, Kansas City, MOGlen Mesaros, MD, Tacoma, WARalph Metson, MD, Boston, MADonald Mettler, MD, Portland, ORTanya K. Meyer, MD, Milwaukee, WIRobert Meyers, MD, Deerfield, ILSamuel A. Mickelson, MD, Atlanta, GARobert Middlekauff, MD, Jacksonville, FLHarry Midgley, III, MD, Jupiter, FLFrancis Milewski, MD, Lincolnton, NCDamir Milicic, MD, Slavonski Brod, Croatia, EOleg Militsakh, MD, Kansas City, KSDavid Milko, MD, Kalamazoo, MIChase Miller, MD, Rochester, NYRandy Miller, MD, Miami, FL

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Robert Miller, MD, United KingdomRobert S. Miller, MD, Cincinnati, OHTimothy Miller, MD, Salt Lake City, UTYang-Gi Min, MD, Seoul, South KoreaOlavo Mion, MD, Sao Paulo, SpainJoseph Mirante, MD, Ormond Beach, FLNatasha Mirza, MD, Philadelphia, PAPradip Mistry, MD, Norfolk, NERyan Mitchell, MD, Pontiac, MIRanko Mladina, MD, CroatiaJeanne Renee Moneyhun, MD, Rockville, MDDenise C. Monte, MD, E. Setauket, NYJ. Spencer Mooney, MD, Brookhaven, MSEric J Moore, MD, Rochester, MNH. Christopher Moore, MD, Fullerton, CAWilliam Moran, MD, Glenview, ILAlice Morgan, MD, Cullman, ALCharles Morgan, MD, Birmingham, ALWarren E. Morgan, MD, Houston, TXJohn Richard Morris, Jr., MD, Louisville, KYWinsor Morrison, MD, Hollister, MOTodd Morrow, MD, West Orange, NJRichard A. Morton, Jr., MD, El Paso, TXRon L. Moses, MD, Houston, TXMark Mount, MD, Edina, MNZan Mra, MD, Scarsdale, NYBrooks Mullen, MD, Sequin, TXChristopher Muller, MD, Galveston, TXKarsten Munck, MD, San Francisco, CAKanit Muntarbhorn, MD, Bankok, ThailandHarlan Muntz, MD, Salt Lake City, UTJames Murata, MD, Boca Raton, FLMichael Murphy, MD, Minneapolis, MNAndrew Murr, MD, San Fransisco, CAJohn Murray, MD, West Palm Beach, FLNguyen My, MD, VietnamJeffrey Myers, MD, Houston, TXLarry Myers, MD, Dallas, TXNathan Nachlas, MD, Boca Raton, FLY. M. Naci, MD, Startford, CTRobert Naclerio, MD, Chicago, ILRavi Nadarajah, MD, Indiana, PAMatthew Nagorsky, MD, Philadelphia, PASrikanth I Naidu, MD, Memphis, TNVincent Nalbone, MD, Las Vegas, NVDonald Nalebuff, MD, Hackensack, NJIsaac Namdar, MD, New Yrok, NYAri Namon, MD, Sharon, CTMohsen Naraghi, MD, Tehran, Iran

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David Nash, MD, Stoneham, MARichard Nass, MD, New York, NYCarl Nechtman, MD, Birmingham, ALH. Bryan Neel, III, MD, Phd, Rochester, MNBrian Neff, MD, Philadelphia, PALeon Neiman, MD, Akron, OHErik G Nelson, MD, Gurnee, ILMark Nelson, MD, Cleveland, OhMichael Neuenschwander, MD, Riverdale, GAAlfred Neumann, MD, Mobile, ALLeonard Newton, MD, Ithaca, NYAnthony Nguyen, MD, Buffalo, NYHenry Nguyen, MD, La Habra, CAHoa Van Nguyen, DO, Olympia Fields, ILNghia Nguyen, MD, Detroit, MIQuoc Nguyen, MD, Huntington Beach, CAPaul Nieberding, MD, Burlingame, CABrad Nitzberg, MD, Boca Raton, FLPhillip Noel, MD, Abbeville, LAMichael Nordstrom, MD, Milwaukee, WIPaul Norman, MD, Manchester, CTJoel Norris, MD, West Monroe, LAFrederick Nunnally, MD, Dothan, ALThomas O\’Donnell, MD, Danville, PAJohn O\’Neill, MD, Westfield, MARobert Oberhand, MD, Westfield, NJNeal Obermeyer, MD, Port Huron, MIJohn Odess, MD, Chelsea, ALHiroshi Ogasaware, MD, Kobe, JapanJohn Oghalai, MD, Houston, TXT. Metin Onerci, MD, TurkeySeth Oringher, MD, Rockville, MDRichard Orlandi, MD, Salt Lake City, UTLaura Orvidas, MD, Rochester, MNJohn Osguthorpe, MD, Charleston, SCFrans Ostyn, MD, BelgiumRalph Glen Owen, Jr., MD, Augusta, GAStuart Owens, MD, Mt Pleasant, SCMichael Paciorek, MD, Syracuse, NYEdwin Page, MD, Columbus, GAJohn Pallanch, MD, Sioux City, IOPietro Palma, MD, ItalyJames Palmer, MD, Philadelphia, PAWilliam Panje, MD, Chicago, ILRaymond V. Paolini Jr., MD, Buffalo, NYAriadna Papageorge, MD, New York, NYMichael Papsidero, MD, Garden Heights, OHAlbert Park, MD, Salt Lake City, UTStephen Park, MD, Charlottesville, VA

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Francis Parnell, MD, Ross, CATodd Parnes, DO, Lake Worth, FLNigel Pashley, MD, Denver, COThomas Pasic, MD, Madison, WIWilliam E Pate, MD, DeLand, FLAnit Patel, MD, Bronx, NYAnkit M Patel, MD, Chicago, ILKalpesh Patel, MD, London, United KingdomElizabeth Payne, MD, Robbinsdale, MNPaul Pedersen, MD, Oakland, CAMichael Peery, MD, Memphis, TNAlejandro Perez, MD, ChileDonald Perez, MD, Loma Linda, CAByron Perry, MD, Phoenix, AZCurtis J Perry, MD, East Greenwich, RISteven Peskind, MD, Plano, TXBruce Peters, DO, Toms River, NJJames Peterzell, DO, Saint Louis, MOCharles Petrillo, MD, Clinton, CTGary Petrus, MD, N Little Rock, ARGeorge Petti, MD, Redlands, CAJohn Pflug, MD, Kearney, NEPerry Phillips, MD, Sheboygan, WISupote Phipatanakul, MD, Saint Louis, MOJay Piccirillo, MD, Saint Louis, MOWilliam Pierce, MD, Batavia, NYRobert Pincus, MD, New York, NYStephen Pincus, MD, Marina Del Rey, CATimothy Pine, MD, Reno, NVJayant M Pinto, MD, Chicago, ILJames Pitcock, MD, Mobile, ALSteven Pletcher, MD, San Francisco, CARoger Plotkin, MD, New City, NYAlan Pokorny, MD, Park City, UTGlen T. Porter, MD, Galveston, TXLouis Portugal, MD, Chicago, ILEdward Porubsky, MD, Augusta, GAWilliam Potsic, MD, Philadelphia, PAW. Bruce Povah, MD, CanadaJeffrey Powell, MD, DDS, FACS, Chesapeake, VALoring W. Pratt, MD, Fairfield, MEJohn C. Price, MD, Lutherville, MDJordan Pritikin, MD, Chicago, ILChristine Puig, MD, Auburn, WAPelayo Vilar Puig, MD, Edo, MexicoRonald Pulli, MD, Pittsford, NYLiana Puscas, MD, Sacramento, CAJoseph Puzzi, MD, Pottsville, PAMelissa Pynnonen, MD, Ann Arbor, MI

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Timothy Queen, MD, Newport News, VAChris Quilligan, MD, Fulelrton, CARichard Quisling, MD, Hermitage, TNJean-Jacques Rafie, MD, McKinney, TXSherif Ragheb, MD, Moline, ILB Manrin Rains, MD, Cordova, TNHassan H Ramadan, MD, Morgantown, WVAlexander Ramirez, MD, San Francisco, CAEmilio Godoy Ramirez, MD, CHILEElizabeth Ransom, MD, Bloomfield Hills, MIVittal Rao, MD, Wappingers Falls, NYDouglas E. Rapisarda, MD, Two Rivers, WIChristopher H. Rassekh, MD, FACS, Morgantown, WVAdrian Ratinoff, MD, ArgentinaEdward Razim, MD, Oak Brook, ILEdward Reardon, MD, Quincy, MAElie Rebeiz, MD, Boston, MAPatrick Reidy, MD, Detroit, MIJacquelyn Reilly, MD, Bronx, NYSeth Reiner, MD, Littleton, COMark Reinke, MD, Green Bay, WIAnthony Reino, MD, New York, NYBruce Reisman, MD, Oceanside, CAWilliam J. Remington, MD, Decorah, IAAngelo Reppucci, MD, Memphis, TNTodd Reulback, MD, Lewisville, NCDukhee Rhee, MD, Bronx, NYEdward Rhee, MD, Pomona, NYTheodore B. Rheney, MD, Asheville, NCDale Rice, MD, Los Angeles, CAHarry J. Richter, Jr., MD, Belfast, MEWilliam Richtsmeier, MD, Phd, Cooperstown, NYSeth Riddle, MD, Provo, UTAnthony A. Rieder, MD, Milwaukee, WIMichael Riley, DO, Largo, FLNabil M. Rizk, MD, EgyptJeffrey Roach, MD, Bronx, NYWade Robinette, MD, Grandview, MOC. Robinson, MD, Albuquerque, NMDonald Rochen, DO, West Bloomfield, MIBret Rodgers, MD, Cleveland, OHHector Rodriguez, MD, New York, NYJeffrey D. Roffman, MD, Tinton Falls, NJShawn E. Rogers, MD, Edmonds, WAAnthony Rogerson, MD, Monroe, WIHwan-Jung Roh, MD, KoreaRenato Roithmann, MD, BrazilJohn H Romanow, MD, Burlington, MAAlexander A Romashko, MD, Maywood, IL

93

J. Lewis Romett, MD, Colorado Spring, COThomas Romo, III, MD, New York, NYWalter Rooney, MD, Cincinnati, OHInell C. Rosario, MD, Saint Paul, MNRoger Rose, MD, S. Salem, NYJohn Rosedeutscher, MD, Hermitage, TNMarc R Rosen, MD, Philadelphia, PAZvi Rosen, MD, IsraelDavid Rosenberg, MD, Cranford, NJSeth Rosenberg, MD, Sarasota, FLMarc Rosenthal, MD, Sicklerville, NJDeborah Rosin, MD, Martinsville, NJArthur Rosner, MD, Sterling Hts., MILouis Rosner, MD, Rockville Center, NYAdam Ross, MD, Philadelphia, PADouglas Ross, MD, New Haven, CTEdwin B. Jr. Ross, MD, Gretna, LAErin J Ross, RN, Cleveland, OHEdward Rubin, MD, Denville, NJRan Rubinstein, MD, Newburgh, NYChristopher Rucker, MD, FACS, Spartanburg, SCDavid Rudman, MD, Overland Park, KSCharles Ruhl, MD, Providence, RIC. Allen Ruleman, Jr., MD, Memphis, TNPedro J Rullan-Marin, MD, San Juan, PrMatthew W. Ryan, MD, Galveston, TXRobert Ryan, Jr., MD, Bonita Springs, FLKelly Rydlund, MD, Lafayette, COJohn Ryzenman, MD, Cincinnati, OHDaryoush Saadat, MD, Los Angeles, CASteven Sabin, MD, East Brunswick, NJMichael Sachs, MD, New York, NYRaymond Sacks, M.D., AustraliaBassem M. Said, MD, Cleveland, OhHamed Sajjadi, MD, San Jose, CAAli Sajjadina, MD, Pittsburgh, PAFrank Salamone, MD, Cincinnati, OHSalah Salman, MD, Boston, MASharyar Samadi, MD, Philadelphia, PAMark Samaha, MD, CanadaRuwanthi Samaranayake, MD, Oakland, CASreeedhar Samudrala, MD, Jackson, MSReynaldo Sanchez, MD, Garland, TXAnthony Sanders, MD, Columbus, INKenneth Sanders, MD, Shreveport, LATarik Sapci, MD, TurkeySholomo Sarfaty, MD, Tel AViv, IsraelJ. R. Sarpa, MD, Bloomington, INAdrian Saurajen, MD, Singapore

94

Phillip R. Say, MD, Omaha, NEMichael Saylor, MD, Hagerstown, MDStanley Schack, MD, Omaha, NESteven Schaefer, MD, New York, NYDean Schaeffer, MD, Goldens Bridge, NYScott Schaffer, MD, Voorhees, NJJoseph Scharpf, MD, Cleveland, OHBarry Schatikin, MD, Pittsburgh, PASara Scheid, MD, Philadelphia, PAKenneth Scheinberg, MD, Wichita, KSMichael Scherl, MD, Westwood, NJMichael Scheuller, MD, San Francisco, CARodney J. Schlosser, MD, Charlottesville, VARichard Schmidt, MD, Philadelphia, PATodd Schneiderman, MD, Bridgewater, NJErik Schoenberg, MD, West Orange, NJKenneth Schoenrock, MD, Toledo, OHJerry Schreibstein, MD, Springfield, MAJames Schroeder, MD, Chicago, ILStacey L Schulze, MD, Milwaukee, WISusan Schwartz, DO, Farm Hills, MIHeather Schwartzbauer, MD, Cincinnati, OHJohn Schweinfurth, MD, Nashville, TNCraig Schwimmer, MD, Baltimore, MDJoseph Scianna, MD, Maywood, ILPaul Scolieri, MD, Cleveland, OHMcWilliams Sean, MD, Birmingham, ALBrook M. Seeley, MD, Cleveland, OHMichael Seicshnaydre, MD, Gulfport, MSAllen Seiden, MD, Cincinnati, OHStuart Selkin, MD FACS, Melville, NYJohn Sellers, MD, Norfolk, VAPeter Selz, MD, Swansea, ILBrent Senior, MD, FACS, Chapel Hill, NCGalgano Alejandro Sergio, M, ArgentinaAnthony Sertich, Jr., MD, San Antonio, TXMerritt Seshul, MD, Murfreesboro, TNMaher Sesi, MD, Redondo Beach, CAReuben Setliff, III, MD, Sioux Falls, SDGuy Settipane, MD, Providence, RIGavin Setzen, MD, Albany, NYMichael Setzen, MD, Manhasset, NYHoward Shaffer, MD, Fort Worth, TXFrank Shagets, Jr., MD PC, Joplin, MOAnand Shah, MD, Detroit, MIShefari Shah, MD, Chicago, ILUdayan K. Shah, MD, Philadelphia, PADjakhangir Shamsiev, MD, UzbekistanWeiru Shao, MD, Minneapolis, MN

95

Adam Shapiro, MD, St. Thomas, VIBarry Shapiro, MD, Briarcliff Manor, NYJack Shapiro, MD, Old Westbury, NYLawrence Shapiro, MD, Los Alamitos, CANina Shapiro, MD, Los Angeles, CAStanley Shapshay, MD, Boston, MADaniel Sharkey, MD, Stuart, FLPramod Kumar Sharma, MD, Salt Lake City, UTMichael B. Shaw, MD, Tulsa, OKFrank Shechtman, MD, Armonk, NYDavid Sherris, MD, Rochester, MNAlan Shikani, MD, Baltimore, MDDavid Shoemaker, MD, Greensboro, NCMichael Shohet, MD, New York, NYMerrit Shshul, MD, Birmingham, ALJoseph Siefker, MD, Meridian, MSMichel Siegel, MD, Houston, TXTimothy Siglock, MD, Jefferson Valley, NYJason B Sigmon, MD, Omaha, NEHarvey Silberman, MD, Elkins Park, PASeth Silberman, MD, Solon, OHMichael J. Sillers, MD, Birmingham, ALSteven Silver, MD, Albany, NYDamon Silverman, MD, Shaker Hts., OHJohn Simmons, MD, Jasper, ALGeorge Simpson, MD, Buffalo, NYHugh Sims, III, MD, Bowling Green, KYJohn Sinacori, MD, Syracuse, NYBhuvanesh Singh, MD, New York, NYPradeep Sinha, MD PhD, Atlanta, GAAbraham Sinnreich, MD, Staten Island, NYDavid Slavit, MD, New York, NYBeatrice Smith, MD, Anniston, ALBruce M. Smith, MD, Fort Collins, COJoe Frank Smith, MD, Dothan, ALLorraine M. Smith, MD, Los Angeles, CAMaynard Smith, MD, Richmond, VARonald Smith, MD, Bronx, NYTimothy L. Smith, MD, MPH, Milwaukee, WIGary Snyder, MD, Bayside, NYMary C. Snyder, MD, Omaha, NECarl Snyderman, MD, Pittsburgh, PAAlan Sogg, MD, Russell, OHRaymond Soletic, MD, Manhasset, NYAhmed M.S. Soliman, MD, Philadelphia, PADoron Sommer, MD, CanadaMichael Spafford, MD, Albuquerque, NMRobert Spears, MD, San Antonio, TXAndrew Ryan Specter, MD, Philadelphia, PA

96

James E. Spier, MD, El Paso, TXJames Spoden, MD, Cedar Rapids, IACarl Sputh, MD, Indianapolis, INBrendan Stack, Jr., MD, Hershey, PASarah Stackpole, MD, New York, NYHeinz Stammberger, MD, Graz, AustriaJames Stancil, MD, Indian Wells, CAJames Stankiewicz, MD, Maywood, ILRalph Stanley, MD, Republic of SingaporeRobert Stanley, MD, Middleton, WIEdward Starinchak, MD, Granville, OHGregory Stearns, MD, Chula Vista, CAKirk Steehler, DO, Erie, PAIra Stein, MD, Livonia, MIJeannine Stein, MD, Cleveland, OhAlbert Steiner, MD, Owings Mills, MDVernon H. Stensland, MD, Sioux Falls, SDBruce Sterman, MD, Akron, OHMichael Stevens, MD, Sandy, UtDavid Steward, MD, Cincinnati, OHMichael Stewart, MD, Houston, TXGerald Stinziano, MD, Buffalo, NYJ. Pablo Stolovitzky, MD, Snellville, GAWilliam Stone, MD, Concord, NHJohn Stram, MD, Boston, MAMichael Strand, MD, Hauugesund, NorwayVictor Strelzow, MD, Irvine, CAScott P. Stringer, MD, MS, FACS, Jackson, MSMichael Strodes, MD, Cleveland, OhMarshall Strome, MD, Cleveland, OHEdward Bradley Strong, MD, Sacramento, CAMariel Stroschein, MD, Scottsdale, AZWilliam Stubbs, MD, Vero Beach, FlFred J. Stucker, MD, Shreveport, LAHoward Stupak, MD, San Francisco, CADas Subinoy, MD, Durham, NCJoseph Sugerman, MD, Beverly Hills, CAKrishnamurthi Sundaram, MD, Staten Island, NYCharles Suntra, MD, Brockline, MADana Suskind, MD, New Orleans, LAGalli Suzanne Kim, MD, New York, NYRonnie Swain, MD, Mobile, ALRonnie Swain, Jr., MD, Atlanta, GAGreg Swanson, MD, Detroit, MILisa Szubin, MD, Englewood, NJThomas Tami, MD, Cincinnati, OHHasan Tanyeri, MD, Chicago, ILM. Eugene Tardy, MD, Chicago, ILRobert Tarpy, MD, Lafayette, LA

97

Jacob Tasher, MD, Slingerlands, NYBarry Tatar, MD, Glen Burnie, MDSherard Tatum, MD, Syracuse, NYJohn Taylor, MD, La Mesa, CARobert Taylor, MD, Durham, NCBenjamin Teitelbaum, MD, Milwaukee, NYSu Teoh, MD, Indianapolis, INJeffrey Terrell, MD, Ann Arbor, MIErica Thaler, MD, Philadelphia, PADai Thanh, MD, VietnamStanley Thawley, MD, Saint Louis, MOHilary Timmis, Jr., MD, Bellvue, OHWyatt To, MD, Weston, FLDiana Tobon, MD, Miami, FLPaul Toffel, MD, Glendale, CALawrence Tom, MD, Philadelphia, PAVincent Toma, MD, W Bloomfield, MIStephen Toner, MD, Panama City, FlRobert Toohill, MD, Milwaukee, WIRichard Trevino, MD, San Jose, CAMatteo Trimarchi, MD, ItalyWilliam Trimmer, MD, Reno, NVMinh Trong, MD, VietnamEwen Tseng, MD, Plano, TXCharles Tucker, MD, West Hartford, CTRalph Tyner, MD, Davenport, IAWilliam Updegraff, MD, Poughkeepsie, NYSusan Urben, MD, Eugene, ORBenito Uy, MD, Quezon City, PhMichael Vaiman, MD, PhD, IsraelMahlon VanDelden, MD, Evansville, INHannah Vargas, MD, Albany, NYSamuel Varghese, MD, Cincinnati, OHCheryl Varner, MD, Jackson, MSPaul Vastola, MD, Brooklyn, NYWinston Vaughan, MD, Stanford, CALeopoldo Velez Rios, MD, MexicoT Venkatesan, MD, Chicago, ILGiri Venkatraman, MD, Atlanta, GAMichael Vietti, MD, Mansfield, OHRaul Vila, MD, Puerto RicoPelayo Vilar-Puig, MD, Mexico City, MexicoDouglas Villaret, MD, Gainesville, FLDaniel Viner, MD, Cleveland, OHThomas Viner, MD, Iowa City, IAEugenia Vining, MD, New Haven, CTYvette Vinson, MD, Rochester, NYRichard L. Voegels, MD, Sao Paulo, BrazilErich Voigt, MD, New York, NY

98

David Volpi, MD, New York, NYMark A. Voss, MD, Fairbanks, AKDaniel D Vukas, MD, Matwood, ILBryan G Wachter, MD, Anchorage, AKRichard Waguespack, MD, Birmingham, AlGlenn Waldman, MD, Los Angeles, CACurtis Walsh, MD, Maywood, ILManish Wani, MD, Katy, TXRobert Ward, MD, New York, NYWalter Ward, MD, Winston Salem, NCSteve P. Warman, MD, Glen Head, NYKurtis A. Waters, MD, Brainerd, MNDaniel Watson, MD, San Antonio, TXMark Wax, MD, Portland, OREdward Weaver, MD, MPH, Seattle, WALyle D. Weeks, MD, El Paso, TXRichard Wehr, MD, Greer, SCJulie Wei, MD, Rochester, MNDudley Weider, MD, Lebanon, NHDebra Weinberger, MD, Cody, WYSamuel Welch, MD, PHD, Little Rock, ARHans-J Welkoborsky, MD, DDS, PhD, GermanyAlvin Wenger, MD, Land o Lakes, FLBarry Wenig, MD, Chicago, ILLawrence Weprin, MD, Dallas, TXJeffrey Werger, MD, FRCSC, FACS, CanadaJohn Werning, MD, Toledo, OHJoseph West, MD, Kirkwood, MORalph F Wetmore, MD, Philadelphia, PAErnest A. Weymuller, Jr., MD, Seattle, WAMark Whitaker, MD, Danville, PAJames White, MD, Dubuque, IARonald Whitmire, MD, Gainesville, GABryan Wilcox, MD, Syracuse, NYAndrea Williams, MD, Buffalo, NYJack Williams, MD, Sugar Land, TXRobert Williams, MD, East Aurora, NYLorraine Williams-Smith, MD, Los Angeles, CAHobson L. Wilson, MD, Rockfledge, FLKeith Wilson, MD, Cincinnati, OHMark Wilson, MD, Madison Heights, MICharles Wine, MD, Oklahoma City, OKCatherine Winslow, MD, Denver, COWelby Winstead, MD, Louisville, KYBirgit Winther, MD, Charlottesville, VADaniel Wohl, MD, Richmond, VAGregory Wolf, MD, Ann Arbor, MIGabriel Wong, MD, Bronx, NYArthur Wood, MD, Boardman, OH

99

B Tucker Woodson, MD, Menomonee Falls, WIPeter Wormald, MD, Woodville South, SAErin Daniel Wright, MD, CanadaJ Robert Wyatt, MD, Mesquite, TXJohn Wyllie, MD, Saudi ArabiaMichelle Yagoda, MD, New York, NYEiji Yanagisawa, MD, New Haven, CTKen Yanagisawa, MD, New Haven, CTDorise Yang, MD, Chicago, ILKathleen Yaremchuk, MD, Dearborn, MIJames Yee, MD, Folsom, CAJames Yeh, MD, Rockville, MDDavid Yen, MD, Philadelphia, PAThomas Yen, MD, San Francisco, CAMatthew Yetter, MD, Colorado Springs, COAltan Yildirim, MD, TurkeyAnthony Yonkers, MD, Omaha, NEDayton L. Young, MD, Omaha, NEM. Young, PhD, Hines, ILPhilip Young, MD, Los Angeles, CAKathy Yu, MD, Carraboro, NCTaskin Yucel, MD, TurkeyRichard Yules, MD, Boca Raton, FLDavid Yun, MD, Bronx, NYBilal Zaatari, MD, LebanonMark Zacharek, MD, Detroit, MIWarren Zager, MD, Philadelphia, PAGerald Zahtz, MD, Jamaica, NYLloyd Zbar, MD, Glen Ridge, NJJill F. Zeitlin, MD, Pleasantville, NYWarren Zelman, MD, Garden City, NYShane Zim, MD, Los Angeles, CAJeffrey M Zimmerman, MD, Philadelphia, PA

100

Dr. Maurice H. Cottle Honor Award

For Outstanding Clinical and LaboratoryInvestigation in Rhinology

First Place Gold Medal Winners

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

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

1980 Two Awards GivenGrowth Pattern of the Rabbit Nasal Bone RegionA Combined Serial Gross Radiographic Studywith Metallic ImplantsBernard G. Sarnat, MD, Los Angeles, CAAbbee Selman, DDS, Los Angeles, CA

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

1984Nasal Problems in Wood Furniture Workers –A Study of Symptoms and Physiological VariablesBorje Drettner, MD, SwedenBo Wihlelmsson, MD, Sweden

1987Eustachian Tube and Nasal Function During PregnancyA Prospective StudyCraig S. Derkay, MD, Pittsburgh, PA

1988The Effecto of Kiebsiella Ozenae on Ciliary Activityin Vitro: Implications for Atrophic RhinitisJonathan Ferguson, MD, Mayo Clinic, Rochester, MN

1990The in Vivo and in Vitro Effect in Phenylephirine(Neo Synephrine) on Nasal Ciliary Beat Frequencyand Mucoolliary TransportP. Perry Phillips, MD, Mayo Clinic, Rochester, MN

101

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

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

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

1996Capsacin’s Effect on Rat Nasal MucosaSubstance P ReleaseFrederick A. Kuhn, MD, Savanah, GA

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

2000Capsacin’s Effect on Trigemunal NucleusSubstance P ReleaseFrederick A. Kuhn, MDSavannah, Georgia

2002Bioengineering of Cartilage Using Human NasalChondrocytes Propagated in Microcarrier Spinner CultureAlan H. Shikani, MD, David J. Fink, PhD, Afshin Sohrabi,M.H.S., Phong Phan, BS, Anna Polotsky, MD, David S. Hunger-ford, MD, Carmelita G. Frondoza, PhD,LOCATION??

102

International Research Award

2002Recording of the Electro-olfactogram (EOG) UsingExternally Placed ElectrodesChurunal K. Hari, F.R.C.S., Liwei Wang, PhD, Tim J.C. Jacob,PhD

103

Golden Head Mirror Honor AwardFor Meritorious Teaching

in Rhinology

The Golden Head Mirror Honor Award was first givenby Dr. Cottle to colleagues who were chosen because of“Meritorious Teaching in Rhinology.” The first pair ofGolden Head Mirror cuff links were given by Dr. Cottleto Dr. George Fisher in 1948.

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

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

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

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

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

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

HRichard B. Hadley, US*Robert M. Hansen, US*

104

Edward W. Harris, US*Raymond L. Hilsinger, US*Kenneth H. Hinderer, US*Leland R. House, USSandy Hoffman, USEgbert Huizing, The Netherlands

JGerald F. Joseph, US

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

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

MHenry Merriman, US*Lewis E. Morrison, US

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

OJoseph H. Ogura, US*Harold Owens, US

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

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

SPieter H. Schmidt, The NetherlandsThomas C. Smersh, USMaynard P. Smith, USPinckney W. Snelling,US*Carl B. Sputh, USHeinz Stammberger, Austria

105

Albert Steiner, US*Sydney L. Stevens, US*Fred Stucke, USGiorgio Sulsenti, ItalyEdward A. Swartz, US

TWilliam H. Tenny, USH. Ashton Thomas, US*Richard Trevino, USCharles A. Tucker, US

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

* Deceased

106

American Rhinologic SocietyHonorary Members

John J. Ballenger, MDChicago, IL

John E. Bordley, MDBaltimore, MD

Guy L. Boyden, MDPortland, OR

Andres Bustamante Gurria, MDMexico, DF, Mexico

Bernard Butterworth, PhDKansas City, MS

D. Thane R. Cody, MD, PhDPonte Verde Beach, FL

J. Dankmeijer, MD*Leiden, Holland

H.A.E. van Dishoeck*Leiden, Holland

Thomas F. Dogherty, MDSalt Lake City, UT

Matthew S. Ersner, MD*Philadelphia,PA

Valentine H. Fuchs, MD*New Orleans, LA

Branimir Gusic, MOZagreg, Yugoslavia

Tu Guy-Yi, MDBeijing, China

French K. Hansel, MD*St. Louis, MS

James Herbertson, MS, DDS*Kansas City, MS

John A. Kirchner, MDNew Haven, CT

Francis L. Lederer, MD*Chicago, IL

Thomas J. McDonald, MDRochester, MN

Joseph H. Ogura, MD*St. Louis, MS

107

Morey L. Parkes, MDLos Angeles, CA

Anthony A. Rieder, MDMilwaukee, WI

Ryo Tschiass;ny, MD*Cincinnati, OH

Richard C. Webster, MD*Brookline, MA

Jim Zinreich, MDBaltimore, MD

* Deceased

108

american rhinologic society

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