AMERICAN RHINOLOGIC SOCIETY

49th Annual Fall Scientific MeetingSeptember 20, 2003

Orlando, Florida

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.

Learning Objectives: With full participation in the Scientific Ses-sions, the participant should be able to:

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Target Audience: The Scientific Sessions are designed to en-hance opportunities in continuing medical education for physi-cians and other health care professionals in otolaryngology-headand neck surgery. Paid registration and badge are required foradmission to the Scientific Sessions.

Credit Designation: The American Rhinologic Society desig-nates this educational activity for a maximum of 8 hours in Cate-gory 1 credit towards the AMA Physician’s Recognition Award.Physicians should claim those hours of credit actually spent inthe activity.

Program Evaluation and Certificates of Attendance: Participantcomments on program evaluation forms assist Program Advi-sory Committees in determining the direction of future educa-tional activities. We appreciate your input and request that youcomplete a program evaluation in exchange for a certificate ofattendance.

Records of attendance are maintained in the Secretary’s Office ofthe American Rhinologic Society. Requests for certificates maybe made by sending a self addressed, stamped envelope to:

American Rhinologic SocietyMarvin P. Fried, MD, SecretaryMontefiore Medical Center3400 Bainbridge Avenue, 3rd floorBronx, New York 10467

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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 Essentialsand Standards of the Accreditation Council for Continuing Med-ical Education, information about relationship of presenters withcommercial interests will be disclosed in printed materials fur-nished to all participants and announced from the podium.

When an unlabeled use of a commercial product or an investiga-tional use not yet approved for any purpose is discussed, thespeaker is required to disclose that the product in notFDA-approved (labeled) for the use under discussion or that theproduct is still investigational.

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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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2003 Corporate Affiliates Sponsors

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

Platinum ($10,000)Aventis PharmaceuticalsGyrus ENT

Gold ($5,000)Karl Storz Endoscopy-AmericaSinus Pharmacy

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

Bronze Plus ($1,500)Abbott Laboratories

Bronze ($1,000)GE Medical Systems Navigation and Visualization

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

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

December 6, 2003Winter Board of Directors Meeting, New York, NY

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

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

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

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Conference Schedule

September 20, 2003

American Rhinologic Society

8:00 am

Introductions and Meeting Agenda

Donald C. Lanza, MDJames A. Hadley, MD

Surgical Techniques

Moderators

Richard Orlandi, MDStilianos E. Kountakis, MD, PhD

8:05 am

Surgical Revision of theObliterated Frontal Sinus

Joseph Han, MDEvanjon Bilstrom, MD

Todd Kingdom, MDPeter Hwang, MD

Portland, OR

Introduction: Surgical revision of failed frontal sinus oblitera-tion has traditionally been limited to repeat obliteration. How-ever endoscopic techniques may be successful in select cases. Wereview our experience in surgical revision of failed frontal oblit-eration. A management algorithm is proposed.

Methods: Retrospective chart review was performed over a 6year period for patients who underwent surgical revision of anobliterated frontal sinus. Selection for an endoscopic versus ex-ternal approach was guided by CT and MRI findings as well asendoscopic examination.

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Results: Eighteen patients were identified, presenting an aver-age of 9 years from the initial obliteration. 83% (n=15) were ap-proached endoscopically and 17% were approached withrevision obliteration. The mean follow up was 18 months. In theendoscopic group, patients either had mucoceles in the infe-rior-medial aspect of the frontal sinus or incomplete obliterationof the frontal sinus with disease in the pneumatized frontal rem-nant. 85% were successfully managed with a single endoscopicprocedure. 15% required a subsequent obliteration or ablationdue to retained infection or osteomylitis. All the patients are dis-ease free. In the revision obliteration group, patients hadmucoceles in the lateral or superior frontal sinus. All the patientsare disease free.

Conclusion: Select group of patients undergoing revision offrontal obliteration may benefit from endoscopic approach. Dis-ease is localized in the frontal recess or inferior-medial frontal si-nus, endoscopic management may successful in majority ofthese patients. Superior-lateral frontal disease is best approachedexternally. Patients undergoing endoscopic salvage should becounseled about possible revision obliteration if disease persists.

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8:12 am

Management of the Inferior Turbinatein Chronic Sinusitis

Peter J. Catalano, MD, FACSBurlington, MA

Introduction: Nasal obstruction associated with chronic sinusitiscan have multiple etiologies. Despite objective data from com-puter tomography, nasal endoscopy, and rhinomanometry, it canbe difficult to determine what portion of these subjective com-plaints are due to the inferior turbinate(IT). This study examinesthis question and offers recommendations for management ofthe IT in patients with chronic rhinosinusitis(CRS).

Methods: 91 patients with chronic sinusitis (58 atopics) and doc-umented IT hypertrophy underwent endoscopic sinus sur-gery(ESS) for CRS. 76/91 underwent septoplasty. No middleturbinates were resected; the IT was not manipulated.Post-operatively, the ability of the IT to autoregulate was moni-tored (mean follow-up 8.3 months). Persistent IT hypertrophywas treated with radiofrequency(RF).

Results: 46/91 (52%) required radiofrequency of the IT (37%unilateral). 30/58 atopic patients in this group required RF(52%); 37% unilateral. 37/76 who also had septoplasty requiredRF (49%). 47 patients were atopic and required septolasty; 25/47required RF (53%). Overall, 15% of patients, regardless of atopicstatus, required more than 1 RF session. An average of 765 jouleswere delivered per lesion; 11/46 required > 2 lesions perturbinate. On average, RF of the IT was performed 5.4 monthsafter surgery.

Conclusion: 52% of patients undergoing ESS for CRS requiredtreatment of the IT to alleviate nasal obstruction. Atopic statusor associated septoplasty did not effect results. The IT canautoregulate after ESS, but predetermination is difficult. There-fore treatment of the IT is best delayed a minimum of 3 monthsfollowing ESS

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8:19 am

Three Wall Orbital Deompression:Results Using Image Guided Surgry

and Lateral Orbitotomy

Howard L. Levine, MDMark Levine, MD

Cleveland, OH

Introduction: Graves’ ophthalmopathy is a devastating compli-cation from hyperthyroidism causing both cosmetic deformityand ophthalmologic morbidity. When corticosteroids and/or ra-diation is unsuccessful or there is unrelenting inflammation orvisual loss, orbital decompression surgery is performed.

Methods: Twenty-four patients were operated upon using endo-scopic image guided computer assistance to manage the medialand inferior walls. A lateral orbitotomy was used for the third(lateral) wall.

Results: Preoperatively, 13 patients had exposure keratopathyand 11 compressive optic neuropathy. There was an average im-provement in exophthalmus of 5.0mm. Eight patients had pre-operative diplopia. Four developed diplopia postoperatively. Nopatient developed postoperative sinusitis.

Conclusions: These technologically improved methods of de-compression have reduced morbidity to the sinus and providedfunctional and cosmetic excellent outcome.

Conflict details: SinuCare-medical director , MedtronicXomed-consultant, Glaxo Smith Kline-medical advisory board,Astra Zeneca-medical advisory board

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8:26 am

Comparison of Traditional CraniofacialResection and Minimally Invasive

Endoscopic Resection of Anterior Skull BaseNeoplasms

Pete S. Batra, MDMartin J. Citardi, MD, FACSDonald C. Lanza, MD, FACS

Cleveland, OH

Introduction: Craniofacial resection (CFR) has been traditionallyutilized for resection of anterior skull base (ASB) tumors. Theminimally invasive endoscopic resection (MIER) has also beenrecently employed; this strategy facilitates superior visualiza-tion, avoids facial incisions and preserves local structures. Thegoal of this study was to compare the outcome for these two ap-proaches. Methods: Retrospective chart analysis was conductedto identify patients undergoing resection of ASB tumors be-tween January 1995 and January 2003. Demographic data, tumorhistology, and the surgical approach utilized were determined.The average operative (OR) time, blood loss (EBL), hospital stay,and complications were analyzed. Disease-free (DF), overall sur-vival (OS), and recurrence rates were calculated.

Results: Nine patients were managed with the MIER approach,while fourteen patients were treated with the traditional openapproach. Average OR time and EBL for the MIER group were 7hours and 35 minutes and 730 cc, respectively. Average OR timeand EBL for the CFR group were 8 hours and 56 minutes and770 cc, respectively. The average hospital stay for the MIER andCFR groups was 8 and 11.6 days, respectively. Major complica-tions were encountered in 2 (22%) and 7 (50%) patients in theMIER and CFR groups, respectively. The DF, OS, and recurrencerates for the MIER group were 56%, 100%, and 44% at 1.6 years,respectively. The DF, OS, and recurrence rates for the CFR groupwere 57%, 71%, and 43% at 3 years, respectively.

Conclusions: MIER of ASB neoplasia was associated with de-creased operative time and blood loss, fewer complications, anddecreased hospital stay compared with traditional CFR. Survivaland recurrence rates were comparable. MIER should be consid-ered as a viable alternative for the surgical management of ASBlesions.

8:34 am

Discussion

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Moderators

James Stankiewicz, MDHoward Levine, MD

8:39 am

Endonasal Surgery of JuvenileNasopharyngeal Angiofibroma

Metin Önerci, MDOðuz Öðretmenoðlu, MD

Taskýn Yücel, MDAnkara, Turkey

Introduction : Juvenile Nasopharyngeal Angiofibroma(JNA) isone of the benign tumours behaving locally in malignant fashionwhich challenges the surgeon. It originates at the superior mar-gin of the sphenopalatine foramen. It predominantly occurs inadolescent males and accounts for 0.05% of all head and neckneoplasms. Although JNA is histologically benign, it can causesignificant morbidity and on some occasions mortality due toextensive submucosal spread to adjacent structures. The exten-sion of the tumour and the bleeding during surgery makes thesurgery more and more difficult. However with new and the de-veloping facilities such as endoscopy, navigation andembolization we are experiencing a revolution in the surgery ofangiofibroma. Patients : 13 patients with JNA between stage Iand IIIA and endoscopic nasopharyngeal surgery performed.

Results: All patients operated through the nose. The operationtime averaged between 35 minutes and 5 hours. One patient re-curred.

Conclusions :Endoscopic removal of JNA with preoperativeembolization is appropriate for JNA in selected cases. Completetumour removal with minimal morbididty is possible. The clas-sification system and endonasal surgery of JNA will be dis-cussed.

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8:46 am

Endoscopic Frontal Sinusotomy:A Six Year Experience

Thianchai Tangsujarittham, MDRakesh K. Chandra, MD

James N. Palmer, MDDavid W. Kennedy

Philadelphia, PA

Background: Preliminary data has correlated failure of frontalsinusotomy with advanced disease by preoperative CT. This hasled us to review our experience with endoscopic frontalsinusotomy over a 6-year period.

Study Design: Retrospective review.

Patients and Methods: Data was collected regarding patient de-mographics, co-morbidities, previous surgery, preoperative CTfindings, and operative technique. Outcome measures includedpatency at last follow–up and the need for revision after our ini-tial procedure. Results: The study group had a high prevalenceof asthma (44.6%), documented environmental allergies (54.2%),nasal polyposis (60.1%), and history of previous endoscopic si-nus surgery (67.9 %). None of these factors individually corre-lated with outcome. Patency was achieved in 262/301 (87%)after our initial surgery. Sinusotomies that were not patent at lastfollow-up (n=14) or those requiring revision (n=25) were consid-ered failures (39/301; 13%). Failure was associated with a higherincidence of total frontal sinus opacification by preoperative CT(p=.0004). The success rate was highest for frontal sinuses un-dergoing a Draf IIa procedure (91.9%) and lowest for those un-dergoing Draf III (60%). Sinuses in the latter group, however,had more extensive disease by preoperative CT (p=.009). Afterrevision surgery, 285/301 (94.7%) were patent at last follow-up.Mean follow-up was 21.4 months for the successes and 23.3months for the failures (p=NS).

Conclusions: Chronic frontal sinusitis is associated with airwayreactivity and atopic disease. Co-morbid factors may have vary-ing influences in any individual patient, but the overall extent ofdisease, as measured by preoperative CT, appears to correlatewith surgical outcome.

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8:53 am

Endoscopic Sphenopalatine Artery Ligationfor Epistaxis: Clinical Experience

Allison C. Ford, MDRicardo L. Carrau, MDCarl H. Snyderman, MD

Pittsburgh, PA

Objectives: We reviewed our surgical experience with endo-scopic ligation of the sphenopalatine artery for the treatment ofsevere epistaxis to establish its effectiveness and determine rea-sons for failure.

Methods: A retrospective review of medical records was per-formed to identify patients undergoing endoscopicsphenopalatine artery ligation at our institution, from 1998-2003.Records were reviewed for evidence of postoperative complica-tions or recurrent episodes of epistaxis. Routine postoperativecare included 1-2 visits for endoscopic debridement until heal-ing was complete.

Results: Fifty-eight patients underwent endoscopicsphenopalatine artery ligation with or without concurrent ante-rior ethmoid artery ligation. In all cases, epistaxis was immedi-ately controlled. There were no perioperative complications.One early recurrence was due to failure to identify the maintrunk of the sphenopalatine artery with clipping of the lateralnasal branch only. This was associated with early bifurcation inthe pterygopalatine fossa. A late recurrence in one patient wasassociated with collateral flow through a branch of the internalmaxillary artery. This patient was treated with embolization.

Conclusions: Endoscopic sphenopalatine artery ligation with orwithout concurrent anterior ethmoid artery ligation is an effec-tive treatment for severe epistaxis and is associated with mini-mal morbidity. In our opinion, endoscopic ligation is thepreferred treatment for this patient population.

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9:00 am

Race and Gender Differences inFrequency of Skull Base Erosion

in Allergic Fungal Sinusitis

John M. DelGaudio, MDSarah Wise, MD

Giridhar Venkatraman, MDAtlanta, GA

Background: Allergic fungal sinusitis (AFS) is a condition thatcan result in significant bone expansion and erosion. The fre-quency of bone erosion with extrasinus extension has been re-ported in the range of 20%. Previous reports have not describedracial or sex differences in the frequency or degree of bone ero-sion.

Methods: A review of all patients with a diagnosis of allergicfungal sinusitis at a single institution was performed using oper-ative logs and retrospective chart review. Records were reviewedto assure that patients met the criteria for AFS. Radiology re-ports and films were reviewed to determine the presence of si-nus expansion and erosion. Since erosion of bone is common inAFS, only bone erosion with extension of disease into adjacentextrasinus areas, such as the orbit and intracranial cavity, wasevaluated.

Results: 42 patients, 24 males and 18 females, were identifiedwith AFS. Mean age at diagnosis was 24.4 years in 20 AfricanAmerican patients, and 38 years in 22 Caucasian patients. Skullbase or orbital erosion was found in 65% of African Americanpatients, involving 56 separate sites (4.31 per patient), and in27% of Caucasian patients, involving 17 separate sites (2.83 perpatient). Erosion was present in 54% of males (53 sites, 4.1/pa-tient), and 33% of females (20 sites, 3.3/patient). Frequency oferosion was similar in the ethmoid, frontal, and sphenoid si-nuses.

Conclusions: In this series there was a greater incidence and se-verity of bone erosion in African American patients and inmales. This is most likely related to later diagnosis, but may alsorepresent differences in the disease process.

9:07 am

Discussion

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Medical Outcomes

Moderators

Joseph Jacobs, MDKathy Yaremchuk, MD

9:14 am

Outcomes of the Extended EndoscopicApproach for Management of

Inverted Papilloma

Gehua Zhang, MDXavier Rodriguez, M.Sc.

Abdulmohsen Hussain, MDMartin Desrosiers, MD

Montreal, Canada

Introduction: Inverted papilloma (IP) is a benign tumor involv-ing the paranasal sinuses. Complete removal of the papillomaremains the treatment of choice given its tendency to recurrenceand potential for malignancy. Since 1994, we have routinely em-ployed an extended endoscopic approach for the resection of in-verted papillomas. We present our methods and outcomes.

Methods: IP is diagnosed by biopsy before surgery. With CT andMRI, we attempt to identify the sites of origin and extent of IP.Cases with previous medial maxillectomy or invasive diseaseare treated via the open approach. Otherwise, the extended en-doscopic approach is used The tumor is debulked and its attach-ment point(s) identified. Endoscopic medial maxillectomy isthen performed. If maxillary sinus involvement in its anterior,inferior, superior or lateral portion is suspected, a Caldwell-Lucapproach is performed to allow for mucosal excision and com-plete removal of the anterior lateral nasal wall. When laminapapyracea, ceiling of the ethmoid or sphenoid sinus are in-volved, the bony wall is resected. The frontal recess can be ap-proached via Lynch incision or an endoscopic trans-orbitalapproach.

Results: 22 patients were referred for IP. 19 patients were treatedvia the extended endoscopic approach. Average follow-up pe-riod was 23 (3-66) months. Only 3 of 19 patients (16%) presenteda recurrence, which required revision surgery.

Conclusion: The extended endoscopic approach offers a safe, ef-fective and esthetically acceptable treatment of most cases of IP.

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9:21 am

Correlation Between Preoperative SymptomScores, Quality of Life Questionnaires and

Staging with Computed Tomography inPatients with Chronic Rhinosinusitis

Peter John WormaldDavid Wabnitz

Salil NairSouth Australia, Australia

This study evaluates the correlation between pre-operativesymptoms, quality of life questionnaires (chronic sinusitis sur-vey and SNOT-20) and staging on computer tomography.

Design: Prospective cohort study of all consecutive patients un-dergoing surgery for medically non-responsive chronic sinusitis.

Setting: Tertiary Care Centre

Materials and Methods: Two hundred and thirty two patientscompleted the Chronic Sinusitis Survey questionnaire and the20-item Sino-Nasal Outcome Test. A Visual Analogue Symptomscore was also completed. The average age of the patients was44.5 years and the male to female ratio was 1:1.3. The symptomscores of all three questionnaires were compared to the Lundand McKay CT scan score of the sinuses.

Results: The median Lund and McKay CT score was 12. Therewas no significant correlation between the SNOT-20 question-naire and the Lund and McKay CT score (rho = 0.091; p = 0.281).There was a significant correlation (rho = -0.21; p =0.009) be-tween the CSS and the Lund and McKay CT score. There wasalso a significant correlation between a single VAS symptomscore relating to overall sinonasal symptom severity and theLund and McKay CT scan score (rho = 0.178; p = 0.035) as wellas a VAS score based on the sum of 5 sinonasal symptoms (rho =0.258; p = 0.002). Conclusions: The CSS and the VAS symptomscores correlate to the disease severity as measured by the Lundand McKay CT scan score. The SNOT-20 questionnaire does notcorrelate to the Lund and McKay CT scan score.

Conflict details: PJ Wormald receives rolyalties on instrumentsdesigned for Medtronic Xomed, Jacksonville, Florida.

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9:28 am

Correlation Between CT Scores andSymptomatic Improvement After

Endoscopic Sinus Surgery

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

Charlottesville, VA

Objective: Determine the correlation between preoperative CTscores and the improvement of symptom scores in patientstreated by Functional Endoscopic Sinus Surgery (FESS).

Methods: Prospective data collection of patients undergoingFESS at a tertiary medical center over a 2 year period forrhinosinusitis refractory to maximal medical therapy. CT scanswere graded as per the Lund-Mackay system. Patient symptomscores were recorded from the SNOT-20 inventory preopera-tively and at 3,6, and 12 months postoperatively. Correlationwas assessed by the Pearson correlation-coefficient (R).

Results: One hundred and thirteen patients were identified with1 year follow-up. The mean preoperative CT grade was 13.2with mean SNOT-20 Symptom scores of 30.6. Preoperative CTscores did not correlate with preoperative symptom scores(R=0.314). SNOT-20 symptom scores improved 72%, 75%, and77% at 3,6, and 12 month follow-up from preoperative values.Additionally, there was no correlation between preoperative CTscores and percent improvement at 3, 6, and 12 months fol-low-up (R=-0.003, R=-0.015, and R=-0.059).

Conclusion: The severity of rhinosinusitis on preoperative CTscan does not correlate with the severity of symptoms assessedby the SNOT-20 inventory in patients undergoing FESS. Further,preoperative CT scores fail to correlate with the degree of symp-tomatic improvement after FESS. Patients had a mean reductionin symptom scores of 77% after treatment with FESS regardlessof the extent of sinusitis severity as assessed by preoperative CT.

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9:35 am

Patterns of Fungal Infections in Patientswith Cystic Fibrosis

Sarah Wise, MDJohn DelGaudio MD

Todd KingdomGiri Venkatraman

Atlanta, GA

Objective: Our goals in this study were to determine whetherfungi are present in patients with CF, and, more importantlywhether the development of ABPA (Allergic BronchopulmonaryAspergillosis) correlated with the development of AFS (AllergicFungal Sinusitis) in the paranasal sinuses.

Methods: Cultures were collected intraoperatively from twentyconsecutive patients undergoing endoscopic sinus surgery aspart of their CF management. Cultures were obtained fromwithin the sinuses and not from the nasal cavity. Fungal culturesand GMS stains were specifically requested.

Results: Four of the twenty patients undergoing FESS had posi-tive fungal cultures. One patient was noted to have findings con-sistent with AFS. The remaining three patients did not haveallergic mucin, and did not have elevated serum IgE levels. Thetwo patients who had documented ABPA did not have eitherpositive fungal cultures or AFS; conversely, the patient with doc-umented AFS did not have ABPA.

Conclusions: The patients all have been treated for the fungi,and subsequent cultures have been negative (except for the pa-tient with AFS). The patient with AFS is currently undergoingimmunotherapy in addition to his CF therapies. Increasinglyfungi are being recognized as putative pathogens in chronic si-nusitis; this report documents that fungi could have potentialroles in the pathogenesis of sinusitis in cystic fibrosis as well.More importantly, even though patients may have CF, theycould carry concurrent diagnoses of AFS as well. Our report alsoseems to indicate that the presence of ABPA is not a predictor forthe development of AFS.

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9:42 am

Discussion

9:45 am

Break with Exhibitors

10:15 am

Invited Guest Lecture ARS Guest of HonorProf Dr. Claus Bachert

Moderator

James A. Hadley, MD

Immunology of Rhinosinusitis—FromMediators to Classification

Claus Bachert, MD

10:45 am

Questions and Discussion

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Basic Science and Rhinology

Moderators

Brent Senior, MDPeter J. Wormold, MD

11:00 am

Immunohistologic Findings Suggest a KeyRole of Cox-2 in Nasal Polyposis

Jan Gosepath, MDJurgen Brieger, PhD

Elefteria Gletsou, MDWolf J. Mann, MD, PhD, FACS

Mainz, Germany

Introduction: Cyclooxygenases 1 (Cox-1) and 2 (Cox-2) play akey role in arachidonic acid metabolism and in the regulation ofeicosanoid production. The balance of prostaglandin andleukotrien release in respiratory mucosa is important in thepathophysiology and immunology of chronic rhinosinusitis(CRS) and nasal polyposis. Methods: 50 surgical specimens wereimmunohistochemically labeled for Cox-1 and Cox-2. Specimenswere taken from chronically inflamed mucosa (n=25) and fromnasal polyps (n=25) during endonasal sinus surgery. Controlswere obtained from healthy nasal respiratory mucosa (n=15),harvested during turbinate surgery in patients with nasal ob-struction without inflammatory disease.

Results: Analysis revealed that Cox-1 and Cox-2 were labeled inall 50 inflamed / polypoid tissue specimens and in all 15 con-trols. In chronically inflamed tissue the expression of Cox-1 andCox-2 was strongly labeled in the respiratory epithelial liningand in mucosal glandular ducts. In nasal polyps the expressionpattern of Cox-1 was similar, but Cox-2 was much less intenselylabeled in the superficial epithelial cellular lining. Controlsshowed homogenious labeling of Cox-1 and Cox-2 in both tis-sues with little intensity.

Conclusions: These data suggest that Cox-2 is downregulated inepithelial cells of nasal polyps. Cox-1 and 2 are present in highconcentrations in ductal structures of mucosal glands. The rele-vance of these findings has to be discussed with respect to the reg-ulatory function of Cox-2 in eicosanoid release and the role of thelatter in the immunology and pathophysiology of nasal polyps.

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11:07 am

Analysis of Innate Immune Mediatorsin Sinonasal Mucosa

Andrew P. Lane, MDJoseph Vandermeer, MD

Quan Sha, MD, PhDRobert P. Schleimer, MD

Baltimore, MD

Introduction: There is a growing appreciation of the role that na-sal mucosa plays in innate immunity. We have examined the ex-pression of the innate immune receptor Toll-Like Receptor-3(TLR-3) and effector molecules including complement factor 3(C3), Properdin B (PB) and Serum Amyloid A (SAA) in culturedairway epithelial cells and human sinonasal mucosa.

Methods: Cultured BEAS2B airway epithelial cells were stimu-lated with the TLR3 agonist Poly(I:C) and then analyzed formRNA for TLR3, C3, PB and SAA using microarrays. MessengerRNA was isolated and tested using Taqman Real Time Polymer-ase Chain Reaction (RTPCR) with primer and probe sets for C3,PB and SAA. Immunohistochemistry was performed on surgi-cally-obtained sinonasal mucosa using antibodies against C3

Results: Stimulation of cultured epithelial cells resulted in in-creased levels of mRNA for C3 (3 fold induction) PB (5.4 fold in-duction) SAA (3.3 fold induction) and TLR3 (2.0 fold induction.)All values achieved statistical significance (p <.05). Analysis ofthe sinonasal mucosa mRNA revealed expression of all fourgenes (SAA=PB>C3>TLR3). Immunohistochemical analysis ofsurgical specimens demonstrated C3 staining ranging from 20%to 80% of the sinonasal epithelium present.

Conclusions: These studies demonstrate that human airway epi-thelial cells and sinonasal mucosa express genes involved in in-nate immunity, including TLR3, and proteins involved incomplement activation. We hypothesize that local production ofcomplement proteins by airway epithelium may play an impor-tant role in host defense in the airway. Ongoing studies will as-sess the regulation of theses genes in sinusitis and withcorticosteroid treatment.

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11:14 am

Endoscopic Biopsy of Human OlfactoryEpithelium as a Source ofViable Neural Stem Cells

Welby Winstead, MDFred J. Roisen, PhD

C.L. Lu, PhDKathleen M. Klueber, PhD

Louisville, KY

Purpose: Stem cells have been found throughout the adult ner-vous system, however the invasive surgery required to harvestthem diminishes their utility for obtaining cell populations forgenetic studies, pharmacologic evaluation or replacement ther-apy for degenerative and traumatic diseases. Olfactoryneuroepithelium (ONe) has attracted attention because of its rel-ative accessibility and unique regenerative potential. ONe con-tains a stem cell population that accounts for its regenerativecapacity. In our lab, cultures of ONe from cadavers have beenshown to yield populations of mitotically active neurosphereforming cells (NSFC) that have characteristics of neural progeni-tors. We describe the results of our studies to develop safe, reli-able techniques to harvest NSFC from living donors.

Materials and Methods: Endoscopic biopsy of the ONe was per-formed in 34 subjects recruited from individuals undergoing en-doscopic sinus surgery. Olfactory function was assessed pre- andpost-operatively. Biopsy specimens were cultured in vitro underconditions that favor the development of NSFC.

Results: NSFC emerged in cultures from 12 of 34 individuals.Successful harvest was not found to be dependent on the age orsex of the donor. The superior turbinate, biopsied with an an-gled punch forceps, was found to be a site of high yield forNSFC. There were no complications associated with the proce-dure. ONe biopsy does not have adverse impact on olfactoryfunction.

Conclusion: We establish the feasibility of endoscopic biopsy ofONe for obtaining neural stem cells from living donors.

11:21 am

Discussion

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Moderators

Jay Dutton, MDThomas Tami, MD

11:26 am

Evidence of Bacterial Biofilms onFrontal Recess Stents in Patients with

Chronic Rhinosinusitis

Joel R. Perloff, MDJames N. Palmer, MD

Philadelphia, PA

Background: Bacterial biofilms have been documented on mid-dle ear mucosa in patients with otitis media with effusion andon tympanostomy tubes removed from patients with chronicotitis media. It has been suggested that bacterial biofilms may beresponsible for potentiating disease refractory to antibiotic ther-apy. We hypothesize that bacterial biofilms are present in mu-cosa of patients with chronic sinusitis. Moreover, we believe thatfrontal sinus stents placed during functional endoscopic sinussurgery (FESS) may serve as an easy way to study biofilms, simi-lar to reports of bacterial biofilms on tympanostomy tubes.

Experiment: We studied frontal sinus stents made of silastic thatwere removed from XX patients up to 4 weeks after FESS. Thesestents underwent formalin fixation and subsequent study withscanning electron microscopy (SEM) for the presence of bacterialbiofilms.

Results: We identified evidence of bacterial biofilms on the fron-tal recess stents in 3 of 4 patients under visualization by SEM. 2of these patients had sinus cultures positive for PseudomonasAeruginosa and Staphylococcus Aureus, organisms known toform biofilms. Bacterial biofilms were identified by standardmorphology, including evidence of glycocalyx, water channels,and three-dimensional structure. These images were similarwhen compared to other images in the literature of knownbiofilms.

Conclusions: This is evidence of the presence of bacterialbiofilms on frontal sinus stents in patients with chronic sinusitis.Some of these patients have also shown cultures positive for or-ganisms known to form biofilms. Further study into the role ofbacterial biofilms in perpetuating chronic sinusitis is warranted.

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11:33 am

Acute Exacerbations of ChronicRhinosinusitis (AECS) After EndoscopicSinus Surgery Are Infectious and Caused

by Staphylococcus Aureus andGram-Negative Agents

Abdulmohsen Hussain, MDXavier Rodriguez, MScMartin Desrosiers, MD

Montreal, Canada

Introduction: Despite having undergone endoscopic sinus sur-gery (ESS) for chronic rhinosinusitis (CRS), a percentage of pa-tients will have acute recurrences of symptoms of CRS.Treatment of these patients represents a challenge, as there areno guidelines for management. As reports have suggested ashift to Staphylococcus Aureus (S Aureus) and Gram–negativebacteria after ESS, current treatment strategies derived frommanagement guidelines for acute bacterial maxillary sinusitis(ABMS) may be inappropriate for this population.

Objectives: We propose to evaluate incidence of infection andtype of bacterial flora responsible for acute exacerbations ofchronic rhinosinusitis (AECS) following ESS.

Methods: Between October 2002 and March 2003, patients pre-senting with AECS (at least 12 weeks post-ESS with less than 30day aggravation of baseline symptoms with evidence of puru-lent secretions on nasal endoscopy) underwentendoscopically-guided cultures of the involved sinuses.

Results: 41 consecutive patients meeting criteria were cultured.36 patients (81%) were infected with at least one species. 56 or-ganisms were identified, for an average of 1.4 organisms/pa-tient. Of the 41 patients, 19 grew S Aureus (46%), 10 coagulase –staphylococci (24%), 8 gram- negative agents (19%), and 3 Pseu-domonas Aeruginosa (7%). While 6 patients grew either Strepto-coccus Pneumoniae or Haemophilus Influenzae (14%), only 2patients (5%) grew them as sole agents.

Conclusion: AECS after ESS is associated with infection in 81%of patients. In contrast to ABMS, S Aureus and Gram- agentspredominate. Therapy for post-ESS AECS should include cover-age of these agents. Culture directed antibiotic therapy is recom-mended, particularly in resistant cases.

11:40 am

Discussion25

11:45 am

Poster Moderators Review and Comments

12:00 pm

American Rhinologic Society Business allARS Members invited to attend

Issues confronting the practicing rhinologist

Moderators

Donald C. Lanza, MDJames A. Hadley, MD

12:30 pm

Luncheon Symposium(sponsored by Abbott Labs)

Antimicrobial Update in Rhinology:Perspectives from the Sinus & Allergy

Health Partnership

Michael S. Benninger, MD

Discussion and AudienceResponse Questions

26

Adjunctive Medical andSurgicalTechniques

Moderators

Martin Desrosiers, MDBrad Marple, MD

1:30 pm

Effect of Saline Irrigation on SymptomsAfter Endoscopic Sinus Surgery: A

Randomized, Controlled Clinical Trial

Jayant M. Pinto, MDSamy Elwany, MD

Fuad M. Baroody, MDRobert M. Naclerio, MD

Chicago, IL

Objective: Saline irrigations are commonly recommended afterendoscopic sinus surgery. These irrigations include normal sa-line, a purported treatment of chronic sinusitis which can im-prove sinonasal symptoms, and hypertonic saline, which canpromote mucociliary clearance, a theoretical beneficial effect inthe postoperative setting. Unfortunately, few studies have exam-ined the role of these agents in routine endoscopic postoperativecare.

Methods: We performed a randomized, controlled clinical trialto determine the effect of saline irrigation on symptoms inadults undergoing endoscopic sinus surgery. Patients were ran-domized to receive normal (0.9%) saline irrigations (n=20),hypertonic (3%) saline (n=20), or no irrigation (n=20) in the post-operative period. Subjects were blinded with regard to thesprays. Remaining postoperative instructions and care, includ-ing antibiotics and pain medication were per routine of the at-tending surgeon. A modification of the Chronic Sinusitis Surveywas used to measure symptoms of headache, congestion, pain,insomnia, and drainage, and pain medication usage was re-corded daily until the first postoperative visit.

Results: The groups were matched with regards to age, gender,atopic status, smoking, revision case, septoplasties or use ofpost-operative steroids (P>0.05). Symptoms were mild and painmedication use low. Symptoms of pain and nasal discharge werehigher in the hypertonic saline irrigation groups as compared tothe group with no irrigation during the second and third post-operative days (P<0.05). Additionally, pain symptoms were

27

higher in the normal saline group as compared to the no irriga-tion group on the second postoperative day (P<0.05). In allgroups these symptoms were similar by postoperative day five.This correlated with pain medication usage, which was highestin the hypertonic saline group. There was no difference in symp-tom scores for headache, insomnia, or congestion between thegroups (P>0.05).

Conclusions: Our results suggest that both forms of saline irri-gations do not improve overall patient comfort after sinus sur-gery. The use of saline irrigation after sinus surgery is not usefulfor patient symptomatic comfort and may interfere with compli-ance to other aspects of the postoperative care

28

1:37 pm

Treatment of Allergic Fungal Sinusitis withReduction of Environmental Air FungalLoad and Anti-microbial Nasal Sprays

Donald P. Dennis, MDAtlanta, GA

Introduction: Mayo Clinic study of 9-99 found 93% of all chronicrhinosinusitis (CRS) was due to Allergic fungal sinusitis (AFS).AFS is caused by an immune response to the fungal antigen onthe nasal mucosa. The purpose of the study was to determine ifantigen (fungus) removal in the air and nasal mucosa would re-verse the disease and normalize the mucosa.

Methods: 639 patients with AFS were studied. One-hour gravitySDA agar plate exposures and Endoscopic nasal photographswere accomplished in the patient’s environment before and afterenvironmental remediation. Nasal fungal cultures were accom-plished initially with nasal swabs directly on SDA agar. A proto-col was developed to reduce mold in the environmental air andto reduce mold in the nasal mucosa.

Results: 639 patients were studied over 14 years. 365 of 639 wereable to achieve a mold count of less than 4 per one hour plate ex-posure. 343 of 365 or 94% showed normal nasal mucosa withoutinfection. Of the 22 who failed to normalize the nasal mucosa, 3had lymphoma and 19 had positive nasal fungal cultures. 219did not reduce the mold count below 4 colonies and had variousdegrees of mucosal disease remaining.

Conclusion: AFS is caused by an immune response to fungal an-tigen. When the antigen is removed from the nose and air, theimmune reaction stops and the mucosa normalizes. Exceptionsto this are other underlying diseases or failure to find the loca-tion of mold exposure.

29

1:44 pm

The Role of Mitomycin-C in PreventingSynechia and Stenosis after Endoscopic

Sinus Surgery—A Long Term Follow-Up

Abtin Tabaee, MDClark Huang, MD

Ashutosh Kacker, MDVijay Anand, MD

New York,NY

Hypothesis: Topical application of mitomycin-C reduces the in-cidence of stenosis and synechia formation following endoscopicsinus surgery. Study Design: Randomized, controlled, singleblinded study based in a tertiary care teaching hospital

Material and Methods: After routine endosopic sinus surgery, apledget soaked in mitomycin C (0.5%) was randomly placed intothe middle meatus of one nasal cavity for 5 minutes and apledget soaked in saline was placed in the contralateral side ineach patient. A blinded observer followed the patients for anyevidence of stenosis or synechia formation. The medical recordsof enrolled patients were reviewed for demographics, diagnosis,prior surgery, type of sinus surgery, complications, incidence ofstenosis / synechia and need for further procedures.

Results: 29 patients were included in the final analysis. Themean follow up period was 15 months (range 3-32 months).There were no complications in this series. 8 patients experi-enced 10 episodes of synechia formation and 1 patient experi-enced 1 episode of synechia formation and 1 episode of stenosisof the maxiallary sinus ostium. 7 of the 12 episodes ofsynechia/stenosis occurred on the side of the mitomycin C ap-plication and the remaining 5 occurred on the side opposite tothe mitomycin C application. This was not a statistically signifi-cant difference.

Conclusion: The topical application of mitomycin-C did not de-crease the incidence of stenosis and synechia formation follow-ing endoscopic sinus surgery.

30

1:51 pm

Effect of Estrogen on Olfactory NeuronConnections to the Olfactory Bulb

Samuel G. Shiley, MDKaren J. Fong, MD

Dennis R. Trune, MDPortland, OR

Background: Clinical evidence suggests a possible influence ofestrogen on the olfactory system. Estrogen receptor protein andmRNA have been identified in olfactory receptor neurons, butthe impact of estrogen on olfactory neuron physiology is un-known.

Objective: To determine whether varying serum estrogen levelsaffects the number of olfactory neurons that make a connectionto the olfactory bulb.

Methods: Olfactory neurons in the olfactory epithelium were la-beled using a retrograde tracer (biotinylated dextran amine) in-jected into the olfactory bulb. Labeled neurons were thenquantified in coronal sections of the olfactory epithelium of nor-mal adult female rats (n = 5) and ovariectomized rats receivingeither vehicle (OVX, n = 5), 4 mg E2/kg/day (OVX + E4, n = 5)or 40 mg E2/kg/day (OVX + E40, n = 5) for 2 weeks.

Results: Average olfactory neuron counts were increased in nor-mal animals (79.9 neurons/section) and animals receiving lowestrogen replacement (E4: 96.0) as compared to animals receiv-ing vehicle alone (OVX: 67.2) or high estrogen replacement(OVX + E40: 65.2). However, one-way ANOVA did not demon-strate any significant differences between groups with respect toneuron counts.

Conclusion: Physiologic estrogen levels may have a positive ef-fect on the number of olfactory neurons reaching their target or-gan, the olfactory bulb. High estrogen levels may have aninhibitory effect. However, due to small sample size and highvariance, statistically significant differences were not identifiedin this pilot study.

1:56 pm

Discussion and AudienceResponse Questions

31

Moderators

Don Leopold, MDJohn DelGaudio, MD

2:01 pm

The Use of Acoustic Rhinometry inEvaluation of the Obstructive Sleep Apnea

Patient

Luc G. Morris, MDKelvin C. Lee, MD

Richard Lebowitz, MDJoseph Jacobs, MD

New York, NY

Introduction: The relationship between nasal airway functionand obstructive sleep apnea (OSA) remains unclear. Several in-vestigators have demonstrated that correction of nasal obstruc-tion can significantly improve nighttime breathing and nasalCPAP tolerance. However, nasal obstruction may not play a rolein all cases of OSA; an effective method of stratifying these pa-tients is needed. The patient?s subjective perception of nasal ob-struction may not be the most effective means of evaluating thenasal airway.

Methodology: In this study of thirty patients with OSA, we pro-spectively review the clinical history of nasal symptoms, sleepsymptoms, and physical findings, and perform acousticrhinometry measurements of nasal airway shape and volume,followed by hospital-based polysomnography and nasal CPAPtitration. We compare subjective perception with objective mea-surement of nasal obstruction, and also describe the relationshipof nasal airway caliber to severity of OSA, nasal CPAP titrationlevel, and the relative success of nasal CPAP.

Results: The patient’s reported nasal symptoms often did not re-flect the level of nasal obstruction as found on physical exam oras measured by acoustic rhinometry. While acoustic rhinometrymeasurements were not directly related to OSA severity in allpatients, in many patients acoustic rhinometry appeared to berelated to nasal CPAP titration. These relationships are dis-cussed.

Conclusions: Nasal airway function may be a significant com-ponent of OSA in some patients. The use of acoustic rhinometryalong with physical examination to describe nasal airway ob-struction may be helpful in the evaluation and treatment of theOSA patient.

32

2:08 pm

Effects of the Nasal Muscles onthe Nasal Airway

Matthew A. Kienstra, MDHolger G. Gassner, MD

David Sherris, MDEugene B. Kern, MD

Tampa, FL

Abstract: Introduction: The nasal muscles and their function arenot clearly defined. The nasal muscles are generally thought toact synergistically to produce mimetic motion and affect the na-sal airway. We proposed to examine directly the effects of the na-sal muscles on the nasal airway. Methods: Rhinomanometry wasperformed on volunteers. Following paralysis of the nasal mus-cles with lidocaine, rhinomanometry was performed again tomeasure nasal airway function both with the patient at rest, andattempting to flare his/her nostrils. Each patient’srhinomanometric results (at rest, and attempting to flare the nos-trils) taken prior to injection of lidocaine served as the controlfor comparison of his/her results post injection. The structuraltension of the ala at rest and with active flaring of the nostril wasalso measured, and the results pre- and post paralysis withlidocaine were compared. Results/Conclusions: The data fromboth the stiffness (structural tension) and airflow portions, takentogether, support the following conclusions. Firstly, the paralysiswas significant, although not complete. Clinical and stiffnessdata supported complete paralysis. Airflow data, which wethink most sensitive, supports a statistically significant affect ofthe injection, although incomplete paralysis. All of the evidencesupports an important role for the nasal muscles when activelyused to increase nasal airflow. Secondly, the majority of the evi-dence supports an important resting nasal muscle tension thatopens the nasal airway.

33

2:15 pm

Analysis of Possible Cross-Contaminationwith the Venturi Atomizer System

Joseph M. Scianna, MDJames Chow, MD

Andrew J. Hotaling, MDMaywood, IL

Purpose: The physics implemented by the Venturi atomizer sys-tem suggest a possibility of bacterial colonization and the poten-tial for cross-contamination. A protocol for use of the atomizerand a clinically appropriate demonstration ofcross-contamination has not been established.

Methods/Measures: One control and two test atomizers filledwith 1% pontocaine and 2% ephedrine were used during afive-day study period. Clinic staff were instructed to use a noz-zle tip, a nasal speculum, avoid contact between the atomizerand the patient, and apply a continuous, less than one secondspray to the nasal cavity. Samples were obtained from each ofthe atomizers three times per day, and plated on chocolate agarplates. The number and type of bacterial colony were registered.

Results: No respiratory pathogens grew from any of the platedsamples. Twelve bacterial colonies were plated from 9 of 30 pos-sible culture plates. Of the twelve bacterial colonies formed, 6colonies of coagulase negative staphylococcus, 5 colonies of Ba-cillus sp. and 1 colony of corynebacterium were identified. Therewas no evidence of an increasing number of colonies per plateover time to suggest contamination, nor was there persistence ofany particular bacteria cultured over time to suggest contamina-tion.

Conclusions: There is no risk of contamination of patients withthe use of the Venturi atomizer system as performed in thisstudy. Culture results from this study were consistent with ran-dom culture contamination during the plating and culturing pe-riod. There was no evidence to support the idea of bacterialcolonization of the atomizers.

2:22 pm

Discussion and AudienceResponse Questions

34

Moderators

Peter Hwang, MDRobert Kern, MD

2:27 pm

Utilization and Efficacy of Hyaluronic Acid –Carboxymethylcellulose (HA-CMC) Wafer inPrevention of Synechiae Reformation in the

Clinic Setting

Noam A. Cohen, MDJames N. Palmer, MD

Philadelphia, PA

Introduction: The primary goal of functional endoscopic sinussurgery is the restoration of adequate ventilation andmucocilliary clearance of the nasal sinus cavities. A commoncause for continued sinus disease is lateralized adhesed middleturbinate to the lateral nasal wall. This immediate postoperativeresult requires synechia lysis in the clinic setting. Often thelateralized middle turbinate has intrinsic recoil that causes thetwo newly cut mucosal surfaces to come into opposition result-ing in synechiae reformation. Multiple materials have been usedin our experience to provide a space between these two surfaces.No material has previously reached the ideal space occupying,inert material. We report our experience with the use ofHA-CMC wafer as a spacer following lysis of synchia in theclinic. The intrinsic hygroscopic and inert properties ofHA-CMC are ideal for placement as a spacer and result in opti-mal outcome.

Methods: 15 patients in the immediate post operative periodwere seen in the clinic for routine debridement and found tohave early synechiae formation. Following lysis of these adhe-sion bands HA-CMC was placed as a spacer between the rawmucosal surfaces. Patients were followed on a weekly basis forevidence of synichiae reformation.

Results: In the fifteen patients that HA-CMC were used asspacer there was no evidence of syniciae reformation at 6months followup. There were no complications associated withthe use of HA-CMC.

Conclusions: This study demonstrates the use of HA-CMC as anideal biomaterial for use in the clinic setting to reduce synechiaereformation following lysis in the post operative period.

35

2:34 pm

Platelet Gel in lieu of Packing forEndoscopic Sinus Surgery

Jay M. Dutton, MDKris Larsen, PA-C

Chicago, IL

Background: The use of packing following endoscopic sinussurgery involves significant discomfort for patients and entailsthe risks of infection or even aspiration. Platelet gel is a bloodproduct with excellent hemostatic and wound healing propertiesthat make it theoretically ideal for use in endoscopic sinus sur-gery. While this product has been successfully utilized in a num-ber of medical fields including head and neck applications infacial plastic surgery and oral surgery, its use has not been de-scribed in endoscopic sinus surgery until now.

Methods: This study describes the preliminary use of plateletgel in a small cohort of patients undergoing endoscopic sinussurgery. The basic science of platelet-rich plasma is described,and the operative technique (including a video demonstration),risks, drawbacks and advantages of this procedure are furtherdiscussed.

Results: All patients in this study were successfully managedwithout the use of endonasal packing, with no bleeding compli-cations reported. Initial concerns about postoperative patency ofthe ethmoid sinus cavity and middle turbinate lateralizationwere unfounded. The patients and authors both subjectively feltthat the recovery time was reduced both in terms of symptomsand endoscopic evaluation of the sinus cavities, althoughlong-term that difference was negated.

Conclusions: Platelet gel appears to be a very promising way topromote wound healing and hemostasis while avoiding packingin the postoperative period following endoscopic sinus surgery.These preliminary results support a long-term, prospective con-trolled study on the use of platelet gel compared to traditionalpacking techniques.

36

2:41 pm

Discussion and AudienceResponse Questions

2:45 pm

Break with Exhibitors

3:15 pm

Panel Discussion: Patient Advocacy Issues

Michael Sillers, MD

4:10 pm

Discussion and AudienceResponse Questions

37

Radiographic Evaluation

Moderators

Roy Casiano, MDEugenia Vining, MD

4:10 pm

Radiographic Variation of NasofrontalRecess Anatomy

Alec Beningfield, MDGiridhar Venkatraman, MD

Patricia Hudgins MDJohn DelGaudio, MD

Atlanta, GA

Introduction: Recent application of image-guided surgery andmultiplanar reconstruction allows more precise understanding ofnasofrontal recess anatomy. CT scans of the nasofrontal recess fromprimary and revision cases were reviewed to determine the rela-tionships between nasofrontal recess anatomy and frontal sinusitis.

Methods: A retrospective review of CT scans from primary andrevision frontal sinus cases was performed by generatingmultiplanar reconstructions of the images. Images were ana-lyzed for agger nasi cells, frontal cells, size of the nasofrontal re-cess and presence of frontal sinusitis. Both sides were recordedand analyzed independently.

Results: Frontal sinus cells were present in 31% of primary and25% of revision cases. Agger nasi cells were identified in 91% ofprimary and 43% of revision nasofrontal recesses. With frontalsinus cells present frontal sinusitis was found in 20% of primaryand 22% of revision sinuses. Without frontal sinus cells presentsinusitis was present in 37% of primary and 43% of revision si-nuses. Frontal sinusitis was seen in 30% of sinuses with a resid-ual agger nasi and 36% of sinuses with no residual agger nasi.The mean A-P diameter of the frontal sinus isthmus is 7.2 mmwith no frontal cell present and 8.6 mm with a frontal cell pres-ent. The A-P diameter of the isthmus is 7.7 mm in the presenceof frontal sinusitis and 6.9 mm when sinusitis is not present.

Conclusions: In a group of surgical patients with sinusitis, aggernasi cells and frontal cells are found at similar rates before and aftersurgery, indicating that they are not being completely addressed atsurgery. These residual cells do not appear to impact developmentof recurrent frontal sinusitis after frontal sinus surgery. The size ofthe frontal sinus isthmus is not related to the presence of these cellsand the likelihood of developing sinusitis is not dependent uponthe size of the isthmus in either primary or revision sinuses.

38

4:18 pm

Regions of the Sinus CT Scan thatPredict Symptoms

Eric H. Holbrook, MDChristopher L. Brown, MD

Elizabeth R. Lyden, MSDonald A. Leopold, MD

Omaha, NB

Background: Patients with symptoms associated withrhinosinusitis frequently present to their physicians for care.One commonly used diagnostic tool is the sinonasal computertomography (CT) scan, however, little data exists to correlatesymptoms with CT findings.

Methods: Immediately preceding CT of the sinuses, sixty-threesubjects with no evidence of trauma or previous sinus surgerycompleted the RSOM-31 symptom questionnaire and wereasked to locate areas of pain. Scans were graded according to theLund-Mackay system, and agger nasi and ethmoid bulla cellswere measured. Data from CT scans and symptom/pain ques-tionnaire responses were analyzed for correlations.

Results: The unilateral Lund-Mackay score did not predict areasof pain or any symptom scores from the seven RSOM-31 subsets.Opacification of individual sinuses including agger nasi orethmoid bulla cells did not correlate with site or number of areasof pressure/pain, but did correlate with the RSOM-31 nasal sub-set scores for the right posterior ethmoid sinus, sphenoid sinus,osteomeatal unit, and agger nasi cell. There was no statisticallysignificant correlation between size of the agger nasi or ethmoidbulla cells and symptoms measured by RSOM-31. However cor-relations between the right agger nasi cell size and pain behindthe right eye as well as the left ethmoid bulla size and pain me-dial to the left eye were identified.

Conclusions: Summed measures of unilateral sinusopacification do not correlate with symptoms, howeveropacification of several specific regions do. The size of the aggernasi and ethmoid bulla cells may predict areas of facial pain.

39

4:26 pm

Three-Slice Computerized Tomographyfor Diagnosis

Can Alper Cagici, MDOzcan Cakmak, MD

Cem Hurcan, MDFahri Tercan, MD

Adana, ???

Introduction: Plain sinus radiography is the imaging techniquemost frequently used to investigate suspected sinusitis, but ithas low diagnostic sensitivity. Contiguous paranasal computer-ized tomography (CT) gives detailed information about pathol-ogy, anatomy and anatomical variations of paranasal sinuses,but this method also has limitations. The cost of using this tech-nique for all cases of suspected sinusitis is prohibitive, and com-plete CT scans involve considerable radiation exposure. Incomparison, a model such as three-slice CT for diagnosing andfollowing sinusitis cases would be more economical and wouldgreatly reduce radiation exposure.

Methods: In this retrospective study, three physicians independ-ently reviewed the contiguous coronal paranasal CT studies of136 patients. The same three slices were selected for each case toform the “three-slide CT” exam, and the same physicians inde-pendently evaluated this set. Using the results from the contigu-ous set as the gold standard, we calculated the sensitivity andspecificity of three-slice CT for identifying sinusitis.

Results: The sensitivity and specificity of three-slice CT for iden-tifying inflammatory sinus disease were 92,6% and 95,1%,respectively.

Conclusion: Three-slice CT is a valuable method for diagnosingand following sinusitis cases, and would be cheaper and requireless radiation exposure than contiguous coronal CT. However,despite the high cost and greater radiation exposure, contiguousCT remains the gold standard for evaluating detailed sinus anat-omy and progression of disease.

40

4:34 pm

Analysis of Methods to Assess Frontal SinusExtent in Osteoplastic Flap Surgery:

Transillumination vs. Six Foot Caldwell vs.Image Guidance

Christopher T. Melroy, MDMarc G. Dubin, MD

Brent A. Senior, MD, FACSChapel Hill, NC

Objective: To compare three common methods(transillumination, plain radiographs, and CT image guidance)for estimating the position and extent of pneumatization of thefrontal sinus in osteoplastic flap surgery.

Methods: Axial computerized tomographic (CT) scans and sixfoot Caldwell plain radiographs were performed on 10 cadaverheads. For each head, the soft tissue overlying the frontal bonewas raised and the anticipated position and extent of the frontalsinus at four points was marked using three common methods.The silhouette of the frontal sinus from the Caldwell plain radio-graph was excised and placed in position. Four points at the pe-riphery were also made using information obtained from apassive optically-guided image guided surgery device whiletransillumination via a frontal trephination was also used to esti-mate the sinus extent. The true sinus size was measured at eachpoint and compared to experimental values.

Results: There was no difference between Caldwell and CTguided estimation (p=0.314). A statistically significant differencebetween transillumination and both Caldwell (0.001) and imageguided (p=0.003) methods was seen.

Conclusion: Accurate and precise estimation of the position andextent of pneumatization of the frontal sinus is crucial when per-forming osteoplastic flap surgery. While no difference exists be-tween image guidance and Caldwell radiographs, both methodsare superior to transillumination.

41

4:42 pm

Discussion and AudienceResponse Questions

4:50 pm

Presentation of Awards forResearch and Posters

Allen Seiden, MD

5:00 pm

Closing Remarks

Donald C. Lanza, MDJames A. Hadley, MD

42

Poster Presentations

Flow Cytometry: A Powerful Tool to Analyzethe Inflammation in Nasal Polyps

Murugappan Ramanathan, Jr., MDMatthew W. Ryan, MD

Galveston, TX

Introduction: Nasal polyposis is the ultimate manifestation ofsinonasal inflammation. As such, nasal polyps are a useful tissuemodel to study the processes involved in various diseases whichcause sinonasal inflammation. Commonly applied techniqueslike immunohistochemistry or in situ hybridization provide onlya qualitative description of the inflammatory infiltrate in nasalpolyps. In this study, we introduce a novel flow cytometry-basedapproach to quantitatively study the lymphocyte populations in-volved in nasal polyposis.

Methods: Single cell suspensions were created from resectedpolyp tissue. Cell staining was carried out with FITC/PE/PerCPconjugated monoclonal antibodies for TCR ãä, TCR áâ, CD3,CD8, CD4, CD19, and CD16/56. Cell populations were analyzedby 2 color flow cytometry with a BD FACScan flow cytometerand data analyzed using CellQuest software.

Results: Flow cytometric analysis clearly distinguished discretepopulations of lymphocyte subsets using 4 samples from pa-tients with ‘allergic’ and ‘non-allergic’ polyps. Average lympho-cyte populations consisted of 63% áâ T cells, 3.6% ãä T cells, 28%CD4+CD3+T cells, 27% CD8+CD3+T cells, 8% CD19+B cells,11% Natural Killer Cells, and 7% NK T cells. There was surpris-ing homogeneity of lymphocyte subset populations despite dif-ferent etiologies of nasal polyposis and different degrees ofsteroid exposure.

Conclusion: This study describes a novel method to extract thelymphocytic inflammatory infiltrate from nasal polyps, charac-terize these cells with flow cytometry, and analyze the inflam-matory processes of a variety of diseases which cause nasalpolyposis. Initial results reveal a consistent lymphocyte subsetprofile in eosinophilic nasal polyps regardless of etiology or ste-roid exposure.

43

Choanal Atresia Mistaken as AntrochoanalPolyp in a 13 Year Old Girl; Retrospective

Clues and Surgical Correction

Scott R. Schaffer, MD, FACSVoorhees, NJ

Introduction: A teenage girl with a long history of nasal obstruc-tion/congestion/sinusitis presented to our office with an appar-ent antrochoanal polyp by nasal endoscopy and CT scan.Endoscopic surgery was planned. After removal of the polyp,the nasal airway was seen to be abnormally dilated. Unilateralchoanal atresia was discovered.

Methods: The patient then underwent a secondary endoscopicprocedure. The atretic choanal membrane was resected alongwith the posterior septum and posterior end of the middleturbinate. Mitomycin 2 mg/ml was applied to the membranesbefore an intranasal stent was positioned and sutured in place.The patient was maintained on antibiotics, analgesics, and oraland nasal steroids postoperatively and seen frequently in the of-fice.

Results: Two months after stent removal, the patient was breath-ing well and demonstrated improved resonance of her voice.She could blow her nose and had no signs or symptoms of si-nusitis. Nasal endoscopy confirmed patency of the choana andnormal mucociliary flow. Retrospective review of the CT scanshowed canting of the floor of the nose, lateralization of the lat-eral nasal wall and tilting of the skull base, all of which in-creased the volume of the nasal airway on the involved side.

Conclusions: Unilateral nasal obstruction in older children maybe the result of unrecognized choanal atresia. Careful endo-scopic examination and review of the CT scan may suggest thediagnosis, since findings of abnormal facial growth may be sec-ondary to posterior nasal obstruction. Endoscopic nasal/sinussurgery can be successful at restoring normal function.

Foreign Body of Sphenoid Sinus Following anExplosion: Case Report and Literature Review

Abdulmohsen E. Hussain, MDB. Al-Sabah, MD

M. Desrosiers, MDMontreal, Canada

Introduction: Foreign body of the sphenoid sinus is a rare condi-tion but can be severe because of intimate relationship to vitalstructures. We present successful management of posttraumatic

44

foreign body of the sphenoid sinus, and summarize the litera-ture to outline management guidelines for this rare condition.

Clinical case: A 41-year-old female was referred to our centerwith a chronic complaint of persistent bilateral frontal headacheand nasal obstruction. In 1983 she had been a bystander victimof a bomb explosion, and over the following twenty years sheunderwent numerous reconstructive procedures with multiplesinus procedures at different institutions.

Examination revealed facial deformity with loss of both eyesand extensive scaring. Nasal endoscopy demonstratedposttraumatic changes with damage to the lateral nasal wall, ab-sence of the septum, and extensive crusting with nomucopurulent nasal discharge or any evidence of infection.Computed tomography (CT) of the paranasal sinuses demon-strated evidence of the trauma and an unusual opacification ofthe sphenoid sinus extending into the clivus. Surgical explora-tion was performed via endoscopic sinus surgery (ESS). A totalof 17 fragments of glass were removed from the sphenoid sinus.However, the patient had only partial relief from her headachepost operatively.

Eight weeks later repeat CT scan was performed and showed apersistence of one fragment of glass embedded in the body ofsphenoid. Revision ESS was performed and successfully re-moved it.

Outcome: The patient had immediate relief of symptoms. She re-mains free of headaches and infection six monthspost-operatively.

Endoscopic Drainage of a Petrous ApexCholesterol Granuloma

Carl H. Snyderman, MDAllison C. Ford, MD

Amin B. Kassam, MDPittsburgh, PA

Cholesterol granulomas may arise within the petrous apex of thetemporal bone. Treatment usually consists of drainage of thecyst into the mastoid cavity when complete excision is not feasi-ble. Surgical access may require a middle fossa approach whenpneumatization of the temporal bone is poor. We present a caseof cholesterol granuloma of the petrous apex that was effectivelydrained using endoscopic techniques. A 38 year-old male pre-sented with complaints of unilateral decreased hearing, tinnitus,and facial pain/ pressure. Radiologic studies (CT and MRI)demonstrated an expansile lesion of the petrous apex in closeproximity to the petrous carotid artery. Due to poorpneumatization of the temporal bone, a transnasal approach wasrecommended. An endoscopic sphenoidotomy with drilling of

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bone from the floor of the sphenoid sinus and clivus was per-formed using image guidance. The cyst was entered medial andinferior to the cavernous portion of the carotid artery. A Silasticstent was placed to maintain patency. Postoperatively, his symp-toms were markedly improved and radiological imaging dem-onstrated adequate drainage and placement of the stent.

This represents a unique approach for the drainage of choles-terol granulomas involving the petrous apex. Advantages in-clude avoidance of a craniotomy, faster recovery, minimalpostoperative symptoms, and shorter hospitalization.

The Role of Computer Assisted Surgery inEndoscopic Management of Sino-Nasal

Cerebrospinal Fluid Rhinorrhea

Abtin Tabaee, MDTali Lando, MD

Ashutosh Kacker, MDVijay Anand, MD

New York, NY

Introduction: The management of sino-nasal cerbrospinal fluid(CSF) rhinorrhea remains a challenge despite advances in tech-nology. Although craniotomy affords direct access and exposureto the site of the defect, the associated morbidities support mini-mally invasive extra-cranial approaches.

Materials and Methods: This is a retrospective chart review ofpatients who presented with CSF rhinorrhea to the New YorkPresbyterian Hospital and affiliate institutions between 1994 and2003. Charts were reviewed for indications, location of leak, typeof procedure, prior closure attempts, duration of leak prior toprocedure, graft materials, adjunct materials, intra-operative andpost-operative complications and need for revision.

Results: Data from 27 patients who underwent extracranial re-pair of a CSF leak was analyzed. There were 10 males and 17 fe-males with a mean age of 48 years (range 28-63 years). Theetiology of the leak was previous sinus surgery in 40.7% of thecases, trauma in 22.2% of cases, spontaneous leak in 26%, andskull based surgery causing the leak in 11.1% of patients. Theleak occurred on left side in 56% of cases and bilaterally in only2% of cases. The most common site of leak was the foveaethmoidalis (48.1%), with cribriform plate and sphenoid sinuscomprising a similar percentages of cases (33.3% and 26%, re-spectively). A concomitant encephalocele or meningiocele waspresent pre-operatively in 37% of patients. All patients under-went an endoscopic sinus approach and repair of the defect us-ing graft material. Image guidance was employed in 59.2% offirst attempt repairs. Graft materials used included conchal carti-lage, septal cartilage, temporalis fascia, hydroxyapetite and

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chondral cartilage. Adjunct materials included floseal, tiseal, fi-brin glue and avatene slurry. There were no majorintra-operative complications. After initial attempt, >80% suc-cess rate was achieved. Six patients required a total of 8 revisionprocedures (7 endoscopic closures and 1 ventriculo-peritonealshunt) for recurrent CSF rhinorrhea. Two patients had meningi-tis which resolved without sequelae. The mean length of fol-low-up was 1.7 years (ranges 1 month-8.5 years).

Conclusion: Endoscopic closure of CSF rhinorrhea represents a mini-mally invasive and highly successful procedure. The use of imageguidance may allow the surgeon increased safety and improved ana-tomic orientation, especially in cases of revision sinus surgery.

Isolated Sphenoid Sinusitis AfterPituitary Surgery

Pete S. Batra, MDMartin J. Citardi, MD, FACSDonald C. Lanza, MD, FACS

Cleveland, OH

Background: Literature addressing the incidence and manage-ment of sinusitis after transsphenoidal hypophysectomy issparse. Methods: Retrospective chart analysis was conducted on200 consecutive transsphenoidal procedures at our institutionfrom January 1998 through December 2001. The incidence ofpostoperative sinusitis was determined. Clinical characteristics,management strategy, and outcome were reviewed for patientsevaluated by the otolaryngology service.

Results: Fifteen of the 200 patients (7.5%) developed sinusitis af-ter transsphenoidal surgery. Seven of the patients were sent toour department for further management. Two additional pa-tients were sent from outside institutions. Eight of 9 patients(89%) had isolated sphenoid sinusitis by CT and/or endoscopiccriteria. Most common symptoms included headaches and nasaldischarge present for an average of 1.4 years. Medical manage-ment resulted in resolution of symptoms in 5 of 9 cases (56%).The remainder 4 patients required endoscopic sphenoidotomyfor recalcitrant symptoms. Intraoperatively, inspissated secre-tions and/or fungal balls were identified in 3 cases, while an in-fected fat graft was evident in one case. Sphenoid sinusitissuccessfully resolved in all 9 cases.

Conclusions: A high index of suspicion must be maintained toavoid an inordinate delay in diagnosis of isolated sphenoid si-nusitis after transsphenoidal hypophysectomy, since the presen-tation is typically nonspecific. Aggressive medical and/orsurgical treatment is required for resolution of refractory sinus-itis in this patient population.

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Choanal Stenosis: An Unusual LateComplication of Radiation Therapy for

Nasopharyngeal Carcinoma

Peter M. Shepard, MDSteven M. Houser, MD

Cleveland, OH

Objectives: To report a unique complication of radiation therapyfor nasopharyngeal carcinoma. Methods: We describe the clini-cal history, preoperative evaluation, surgical management, andpostoperative course of a case of acquired choanal stenosis fol-lowing radiation therapy.

Results: The patient, a 39-year-old female, presented with a his-tory of nasopharyngeal carcinoma 16 years prior to presentationthat had been successfully treated with radiation therapy. Uponpresentation the patient complained of decreased nasal air flow.Bilateral choanal stenosis was confirmed per rigid nasal endos-copy. Transnasal endoscopic repair with mitomycin applicationwas performed, and nasal stents were left in place for 6 weeks.Postoperative endoscopic examination showed patent choanaeand a patent nasopharynx without stenosis. The patient contin-ues to have good air flow 9 months postoperatively. Conclu-sions: Choanal stenosis is a recently recognized, rarecomplication of radiation therapy. This is the first report of sucha complication in the West and the first report of successful man-agement of acquired choanal stenosis using mitomycin.

Induced Anosmia

Bruce W. Jafek, MDMiriam Linschoten, Ph. D.

Bruce W. Murrow, MD, Ph. D.Denver, CO

Introduction: Zinc is extensively utilized throughout the body,supporting the activity of approximately 100 enzymes, the im-mune system, wound healing, the senses of taste and smell, andDNA synthesis. Zinc supports normal growth and development.The deleterious effects of both deficiency and toxicity (acute andchronic) are described. Beneficial zinc absorption takes place viaenteral, parenteral, or cutaneous routes. Direct application to theolfactory epithelium, on the other hand, has long been known tobe toxic, producing anosmia. This toxicity is thought to be due tothe direct effect of the divalent zinc ions on olfactory receptorcells. Apparently overlooking this toxicity, however, intranasalzinc gluconate has recently been recommended as a treatment for the common cold.

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Methods: We will present a series of patients with post-zincanosmia. The mechanism of drug toxicity will be analyzed.

Results: While interindividual variation in drug response anddrug toxicity is apparent, anosmia appears to bedose-related and permanent.

Conclusion: Zinc ions remain toxic to human olfactory epithe-lium, and continued reports of total, probably irreversible,anosmia, can be expected as long as intranasal zinc gluconate gelcontinues to be used. The recent extension of the useof to the pediatric age group is particularly alarmingsince this group is less likely to be able to describe the anosmia.Immediate discontinuation of the use of intranasal zinc recom-mended.

“Those who do not learn from history are doomed to repeat it.”— George Santayana (1863-1952), noted philosopher

Acanthamoeba Rhinosinusitis: A Case Studyand Review of the Literature

Amin R. Javer, MDMathew Dickson, MD

Burnaby, Canada

Introduction: To date, only six documented cases ofAcanthamoeba rhinosinusitis have been reported in the worldliterature, and all were in HIV-infected patients. Only two caseshave been treated successfully. Acanthamoeba is felt to be an-other opportunistic pathogen in addition to the already long listof opportunistic pathogens of the nose and paranasal sinusesknown to cause rhinosinusitis in the immunocompromised pa-tient.

Methods: We present a 31 year old end stage HIV-infected malewith a long standing history of chronic rhinosinusitis who pre-sented with a one week history of severe unilateral headachesand peri-orbital pain. Surgical debridement was carried outemergently with removal of an infected lamina papyracea.

Results: Intraoperative cultures were positive for AspergillusNiger, Penicillum and Acanthamoeba was noted in the necroticdebris.

Conclusion: This report identifies Acanthamoeba as a poten-tially fatal cause of rhinosinusitis in the immunocompromisedpatient. Our experience, pathogenesis, diagnosis and potentialtreatment of this rare entity will be discussed and the literaturereviewed.

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Endoscopic Septoplasty and Sinus Surgeryin an Adult with Unrepaired Cleft Palate

Using Transoral Visualization

Scott R. Schaffer, MD, FACSVoorhees, NJ

Introduction: A 54 year old man with unrepaired cleft palatepresented with nasal obstruction and recurrent sinusitis fromseptal deviation. Numerous medicines were unhelpful. Internaland external nasal deformities are associated with the absence ofa nasal floor in patients with cleft palate. Typical anatomic pat-terns have been described, and chronic sinusitis is common.Septal repair in children with cleft palates is controversial be-cause of possible facial growth retardation. In this adult, endo-scopic septoplasty and sinus surgery was planned. The septaltechnique was modified to compensate for the lack of inferiorsupport of the septum. The endoscopic work was performedthrough the nostrils, and visualization was aided by the use of atransoral endoscope.

Methods: The procedure was successfully performed withoutcomplication. The septum was straightened and thinned whilepreserving support struts. Quadralateral cartilage was har-vested, manipulated, then reimplanted; mucoperichondrial flapswere approximated with quilting sutures. Endoscopicethmoidectomy and maxillary antrostomy were also performed.Transoral endoscopic photographs demonstrate the surgicaltechnique. The patient had septal splints for one week and rou-tine postoperative sinus care for several weeks.

Results: The patient’s symptoms resolved postoperatively. Hesuffered no bleeding, infection, hematoma, cicatrix or septal per-foration. His nasal airway and sinus aeration/drainage im-proved bilaterally. He no longer required daily nasal medicinesfor symptom relief.

Conclusions: Endoscopic septoplasty and sinus surgery can besuccessfully and safely performed on adult patients withunrepaired cleft palate using a conservative endoscopic ap-proach.

Incidence of Complications forRadiofrequency Reduction (SOMNUS) of

Base of Tongue Surgery

John H. Romanow, MDBurlington, MA

Introduction: Radiofrequency reduction (SOMNUS) of thetongue base has been described as an alternate method of

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tongue reduction/stiffening procedures. It is typically used inconjunction with other sleep apnea surgeries. Its advantages in-clude simplicity, coupled with a presumed low complicationrate. This study was designed to review the complications of thisprocedure at our institution.

Methods: A two-surgeon retrospective chart review ofintraoperative and postoperative complications in patients un-dergoing sleep apnea surgery, which included SOMNUS to thebase of tongue was performed.

Results: 111 charts were examined. No intraoperative complica-tions were noted. The total complication rate was 9.9% (11/111).Not all of these complications were specific to radiofrequency ofthe tongue base. The total radiofrequency specific complicationrate was 7.2% (8/111) with 6.3% (7/111) of these complicationsbeing mild, and 0.9% (1/111) being severe. Mild complicationsincluded severe tongue ulcers requiring treatment, self-limitedfloor of mouth edema and self limited hypoglossal nerve injury.Severe complications included significant airway obstruction.

Conclusions: SOMNUS to the base of tongue is a safe proce-dure, but not without potential risk. Airway type complicationsall began to occur within 6 hours of completion of the procedure.Recommendations include observation of these patients for atleast 6 hours prior to discharge, and the use of steroidsperioperatively.

Objective Evaluation of Nasal Aiflow UsingNeumotachography

Boris L. Bentsianov MDAndrew Blitzer MD,DDS

New York, NY

Objectives: To determine whether pneumotachography is a reli-able and sensitive technique to detect changes in nasal airflow.

Methods: Patients with no current nasal symptoms or com-plaints were measured using pneumotachography during quietand deep breathing. These baseline flow measures were re-peated to ensure reproducible results. These patients are thentreated with a topical decongestant and re-analyzed. This patientgroup was also treated with nasal saline spray and re-analyzedonce again. This control group was used to ensure that any ben-efit could be attributed to a true vasoconstricting effect, ratherthan simple lubrication of irrigation of the nasal mucosa.

Results: Preliminary data suggests that pneumotachographyprovides reproducinle nasal airflow data. Airflow after using atopical decongestant was significantly greater than at the un-treated baseline and with saline spray alone. Airflow after salinespray alone was statistically similar to the pretreatment airflowrate.

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Conclusions: Current standards for nasal evaluation rely onrhinometric volume assessment and subjective patient accounts.Pneumotachography was able to detect changes in airflow dueto topical decongestant use that were not noted with the use ofsaline alone. We believe objective airflow can be used as moresensitive outcome measure, and can correlate with subjective pa-tient sensation of nasal breathing quality. Further studies withthis promising technique can be applied to objectively assessmedical and surgical treatment outcomes.

Postoperative Endonasal Dressing withPolymeric Membrane Material

P. Perry Phillips, MDSheboygan, WI

A prospective study of 236 patients undergoing 287 nasal surgi-cal procedures was performed. Nasal septal reconstruction(NSR) was performed in 187 and endonasal sinus surgery (ESS)in 85. All patients had polymeric membrane wound dressingmaterial used for their postoperative intranasal dressings. Quan-titative study of pain and bleeding during dressing removal wasnoted on a 0 – 4 scale. Scoring was recorded as follows: 0= nobleeding/ pain, 1 = mild pain/slight bleeding< 1 minute dura-tion, 2 = moderate pain/ hemorrhage lasting >1 minute but notrequiring repacking, 3 = severe pain/ bleeding requiringrepacking, 4 = excruciating pain/hemorrhage requiring return tosurgery. Patients were also monitored for postoperativehemostasis, toxic shock syndrome, synechial formation, dressingmigration, support of septal reconstruction, and dressing odor.NSR patients had a composite pain score of 0.38 and bleedingscore of 0.27. Anterior dressing migration occurred in 2/187 pa-tients and posterior migration in 1/187. No synechiae werenoted in the NSR group. ESS patient’s had a composite painscore was 0.66 and bleeding score of 0.35. . No dressing migra-tions occurred. Non-obstructing synechiae were noted in 2/85ESS patients. Toxic shock syndrome and hypersensitivity reac-tions were not noted in either group. Dressing odor was mini-mal on dressing removal. Immediate postoperative hemostasiswas excellent with no patients requiring repacking of the nose.In summary, polymeric membrane dressings are a safe cost ef-fective intranasal dressing with excellent hemostatic and woundhealing properties

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CT and MRI Characteristics of AllergicFungal Rhinosinusitis

Alexander E. Stewart, MDKurt Hildebrandt, MD

Darrell H. Hunsaker, MDSan Diego, CA

Introduction: The characteristic findings of allergic fungalrhinosinusitis (AFS) on non-contrast CT and gadolinium en-hanced MRI are clinically important for diagnosis and treatmentplanning. These classic findings include a unilateral predomi-nance of disease, and a serpiginous, lamilated appearance of theinvolved sinuses with or without sinus expansion.

Methods: Cases of documented AFS are presented with an ex-amination of their CT and MRI imaging. Intraoperative findingsare correlated with these imaging studies. Other diseases with asimilar radiologic appearance are also presented.

Conclusions: Certain characteristic findings on CT should alertone to the possible diagnosis of AFS. When these findings arenot accompanied by an elevated total IgE, fungal-specific IgE, orpolyps, an MRI should be obtained to assist with the differentialdiagnosis.

Toxic Shock Syndrome and Nasal Surgery

George L. Murrell, MD, FACSPaul Johnson MD

Camp Pendleton, CA

Post septorhinoplasty Toxic Shock Syndrome (TSS) is a rare butpotentially fatal complication. This paper will review a tragiccase, which occurred at a large residency training program. Inaddition, the disease process of TSS and its association with na-sal surgery will be reviewed.

A twenty seven year old female died from TSS after routine na-sal surgery. A detailed chronology of this case will be presented.The case will emphasize how TSS can be insidious in nature. Theclassic symptoms of fever, chill, headache, and rash are not al-ways present at the outset of the disease. Proper preoperativecouseling is critical in early recognition of TSS. The surgeon andthe patient need to have a healthy suspicion that vague constitu-tional symptoms after nasal surgery can represent TSS.Multiorgan system failure and shock can develop quickly aftervague constitutional symptoms.

TSS is associated with colonization of “Staphalococcus aureus”and the production of a toxin. TSS and its association withsuperabsorbent vaginal tampons was well publicized in the

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1980s, however, 11% of TSS cases are unrelated to menstrual cy-cle products.

TSS following nasal surgery is very rare, occurring in about 1 in6,000 cases. Overall mortality estimates are about 1%. Illness on-set is typically 2-48 hours after nasal surgery, however, delayedpresentation of up to 5 weeks has been reported.

In-Office CT Scanning - Enhancement forDiagnosis & Treatment

John T. McMahan, MD, FACSDaniel Carothers, MD

Chicago, IL

The installation of an in-office GE LightSpeed 16 slice CT scan-ner into an office environment will be discussed. The technical,networking, PACS, personel and reimbursement issues will bediscussed. The surgical and medical management ofrhino-sinusitis patients has been greatly enhanced by this mo-dality. The changes in our protocols will be discussed. Thisequipment would be a great addition to any rhinology practicewhich would greatly advance the art and science of the treat-ment of this group of patients.

Eustachian Tube Dysfunction in ChronicRhinosinusitis

Jay M. Dutton, MDNathan Stoikes, MD

Chicago, IL

Background: Symptoms of rhinosinusitis have been relegated to“major” and “minor” in the past, to indicate a possible correla-tion between symptomatology and the likelihood of occurrenceof this disease process. The symptom of eustachian tube dys-function has been categorized as “minor” but there is a paucityof data regarding the presence of this symptom in chronicrhinosinusitis and the likelihood of its resolution with endo-scopic sinus surgery. The aim of this study was to determine thefrequency of otologic symptoms in patients with confirmedrhinosinusitis and the likelihood of their resolution in those pa-tients undergoing endoscopic sinus surgery.

Methods: Questionnaires were obtained from 168 patients whohad undergone prior endoscopic sinus surgery over a five-yearperiod. Patients were asked to evaluate if they suffered fromseveral different potential symptoms of eustachian tube dys-function prior to endoscopic sinus surgery, and whether or notthat symptom changed postoperatively. Their charts were then

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retrospectively reviewed for demographic data and to deter-mine the precise diagnosis and extent of surgery.

Results: 168 patients with confirmed chronic rhinosinusitis re-quiring endoscopic sinus surgery responded to a mailed ques-tionnaire and had charts available for review. The presence ofear congestion was noted in 42% of patients, and this improvedor resolved after endoscopic sinus surgery in 84.3 % of patients.Dizziness was a complaint in 26.9% of patients and this im-proved or resolved postoperatively in 89.3% of patients. 31.3% ofpatients complained of “cracking or popping” of their ears andthis improved or resolved postoperatively in 65.3% of patients.Finally, otalgia was indicated by 15.1% of patients and this im-proved or resolved postoperatively in 84% of patients.

Conclusions: Eustachian tube dysfunction, as manifested byseveral different individual otologic symptoms, is relativelycommon in patients with chronic rhinosinusitis undergoing en-doscopic sinus surgery. The classification of this as a “minor”symptom of rhinosinusitis may need to be re-evaluated. Thesesymptoms tend to improve or resolve in the majority of patientsundergoing endoscopic sinus surgery.

Diagnostic Imaging of Nasal Dermoids inthe Pediatric Patient

Vishvesh M. Mehta, MDAri J. Goldsmith, MD

Brooklyn, NY

Introduction: Nasal dermoid sinus cysts are rare congenital le-sions that result from aberrant embryonal development. Theselesions have the potential for intracranial extension and anteriorskull base abnormalities. Accurate preoperative radiological in-vestigations, especially in the younger pediatric patient, are nec-essary to assist in establishing the diagnosis, precisely locate themalformations and to guide surgical planning. Our study willlook at two cases that highlight the importance accurate preop-erative radiographic assessment of nasal dermoids.

Methods: Two pediatric patients from a tertiary care center usedto emphasize the importance of the proper preoperative radio-graphic evaluation of nasal dermoids, as well as a literature re-view of radiographic imaging of nasal dermoids.

Conclusions: The first patient was accurately diagnosed withintracranial extension on true coronal CT imaging. The other pa-tient was diagnosed with an anterior skull base anomaly on truecoronal CT imaging; which was not appreciated on the origi-nally reconstructed CT coronal image. Detailed imaging of theanterior skull base effectively changed the preoperative surgicalmanagement in both patients. The accurate preoperative radio-graphic evaluation of the dermal cyst or sinuses should exclude

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intracranial extension and anterior skull base abnormalities.These often cannot be appreciated with standard CT protocolsfor pediatric patients. We recommend that pediatric patients di-agnosed with a nasal dermoid be evaluated preoperatively byfine-cut CT scan, in the axial and true coronal planes, not recon-structed computer generated images.

Sellar Floor Reconstruction with NasalTurbinate Tissue after Endoscopic Endonasal

Transsphenoidal Surgery

Omar A. El-Banhawy, MD, PhD,Ahmed N. Halaka, FRCS, PhD,

Abd El- Hafiz Shehab El-Dien, MD,Heshmat Ayad, MD,

Egypt

Background: The emerging endoscopic endonasaltranssphenoidal approach for pituitary adenomas is safe and ef-fective. An intraoperative sellar floor reconstructive method af-ter this approach is challenging.

Objective: To describe a simple method of sellar reconstructionafter endoscopic endonasal transsphenoidal surgery for pitu-itary adenomas by nasal turbinate tissue. Materials andMethods: thirty patients with defects in the floor of the sellaturcica, after endoscopic endonasal transsphenoidal surgery forpituitary adenomas, underwent reconstruction with nasalturbinate tissue. Surgical technique is described.

Results: patients who underwent this sellar reconstruction didnot show postoperative cerebrospinal leak or other complica-tions. Conclusion: nasal turbinate tissue is an excellent source ofdonor material for successful reconstruction of the sellar floor. Itis costless, safe, soft, malleable and easy to obtain in the samefield of surgery with suitable size without inducing side effectsor complications.

Key words: nasal turbinate; Pituitary gland; Reconstruction;Sella turcica; Transsphenoidal endoscopic surgery.

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An Assessment for the Presence of BacterialContamination of Venturi Principle

Atomizers in a Clinical Setting

Mark Rizzi, MDPete Batra, MD

Martin Citardi, MDDonald Lanza, MD

Cleveland, OH

Introduction: Venturi principle atomizers have been criticizedfor potential contamination and disease transmission when uti-lized for the nasal application of medications. A recent labora-tory study reported a high rate of contamination of theseatomizers after their immersion and spraying into a broth con-taining Staphylococcus aureus. The objective of this study wasto determine whether the Venturi type atomizers used regularlyat a busy referral center for sinonasal disorders were contami-nated with bacteria.

Methods: Fifteen venturi type atomizers separately containingeither 2% lidocaine (seven bottles) or 0.05% oxymetazoline (eightbottles) were sprayed onto blood agar plates using standardtechnique for their use. The contents within each bottle’s reser-voir were also cultured onto plates yielding a total sample sizeof thirty specimens. All atomizers assessed in this study were inuse in an active ENT office for one month prior to analysis. Theplates were then incubated at 35° C for 48 hours and then atroom temperature for 72 hours.

Results: Three of our thirty plates grew one colony each of grampositive bacilli, gram positive cocci and staphylococcus species.

Conclusion: No significant microbial growth was reported fromthe atomizer or bottle medium after five days of incubation.Thus, Venturi type atomizers may not be at as high a risk forcontamination as has been suggested by previous reports.

A Targeted Endoscopic Approach to ChronicIsolated Frontal Sinusitis

Roee Landsberg, MDYoram Segev, MD

Michael Friedman, MDAri DeRowe, MD

Tel Aviv, Israel

Introduction: Frontal sinusitis is common and is usually second-ary to inflammatory changes in the anterior ethmoid cells. Con-sequently, chronic frontal sinusitis is usually treated by

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endoscopic anterior ethmoidectomy. Isolated frontal sinusitis isuncommon. In this condition, most of the ethmoid cells are wellaerated and the frontal sinus is involved secondary to anatomi-cal obstruction or inflammatory changes confined to the frontalrecess.

Objectives: To describe a problem-oriented targeted endoscopictechnique where standard anterior ethmoidectomy is unneces-sary in the treatment of chronic isolated frontal sinusitis.

Methods: Between 2000 and 2002 seven patients were diagnosedwith chronic isolated frontal sinusitis refractory to medical treat-ment, as confirmed by CT scan. Patients with isolated frontal si-nusitis secondary to previous ESS (Endoscopic sinus surgery)were excluded. All patients underwent limited ESS that in-cluded uncinectomy and removal of the terminal recess, aggernasi cell or frontal cell. The ethmoid bulla and the maxillary nat-ural ostium were preserved in all patients. The follow-up rangedfrom 6 – 26 (mean 14.6) months. Patients reported significant im-provement, mild improvement, no change or worsening ofsymptoms. Frontal sinus outflow patency was confirmed by en-doscopy, transillumination or a CT scan.

Results: 5 patients reported significant improvement, 1 patientreported mild improvement, 1 patient had no change in hissymptoms. Frontal sinus outflow patency was verified in 6 pa-tients. One patient had frontal sinus recurrent disease.

Conclusion: Chronic isolated frontal sinusitis develops second-ary to frontal recess inflammatory changes and hence can be sur-gically treated by a targeted endoscopic procedure that includesmerely re-establishment of the frontal sinus outflow.

Management of the Lacrimal System DuringMaxillectomy

Ramez Habib, MDGady Har-El, MD

Brooklyn, NY

Background: Oncologic resection of the maxilla requires man-agement of the nasolacrimal sac/duct system (NLS). A variety oftechniques may be used: simple transection, transection withtranscanalicular stenting, drilling of the entire nasolacrimal bonycanal to the inferior meatus with mobilization of an intact NLS,marsupialization of the NLS with or without stenting, and sim-ple transaction with routine delayed dacrocystorhinostomy(DCR) for symptomatic epiphora. Rates of prolonged epiphorarange from 13 to 63%.

Objectives: We present our approach to NLS management dur-ing maxillectomy, and our rates of epiphora.

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Study Design: Review of 220 consecutive patients who underwenttransection of the NLS during medial maxillectomy, completemaxillectomy with preservation of orbital contents, suprastructuremaxillectomy, or maxillectomy as part of anterior craniofacial resec-tion. Patients with primary NLS tumors were excluded. Prolongedepiphora is defined as persistent more than 6 months.

Methods: After exposure of the anterior maxillary wall and infe-rior and medial orbital rim, high speed drill and Kerrisonrongeurs are used to remove the anterior wall of thenasolacrimal canal. The NLS is transected 12-15mm distal to theperiorbita and removed from the canal. Two 4-6mm opposingincisions are made at the distal duct. Two semicircular flaps areeverted, folded and sutured to the proximal sac or periorbita.Transcanalicular stent is not placed.

Results: Two hundred twenty patients underwent theabove-mentioned procedure. Three patients (1.4%) developedprolonged epiphora which required delayed DCR.

Conclusions: Marsupialization of the NLS without stenting pro-vided us with an acceptable low rate of prolonged epiphora.

Endoscopic Excision of a Juvenile OssifyingFibroma of the Anterior Cranial Base

Allison Ford, MDCarl Snyderman, MD

Jennifer Hunt, MDPittsburgh, PA

Juvenile ossifying fibroma (JOF) is a benign fibro-osseous neo-plasm that may involve the paranasal sinuses. It is a variant ofossifying fibroma and is characterized by locally aggressivegrowth. Treatment consists of complete resection of the mass tominimize the risk of recurrence. We present a case of a6-year-old girl with JOF of the nasal cavity with anterior cranialbase involvement. With the aid of image guidance, the mass wasresected using endoscopic techniques. A sublabial incision wasused to enhance exposure and provide greater access for instru-mentation. With six months follow up, there has been no evi-dence of recurrence. Although these tumors are typicallyresected using open surgical approaches, this patient’s tumorwas resected endoscopically with the avoidance of the morbidityof a craniotomy. Review of the literature documents similar suc-cess using endoscopic techniques. Technological advances in in-strumentation, navigational systems, and hemostatic andreconstructive materials now allow endoscopic resection of be-nign and malignant neoplasms involving the anterior cranialbase. As additional experience is gained with endoscopic tech-niques, the role of endoscopic surgery for the management ofbenign and malignant neoplasms of the anterior cranial basewill become better defined.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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, MD, Savannah, 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, San Diego, CA

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International Research Award

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

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

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American Rhinologic SocietyResident Research Grant Award

2003Nasal Mucosal Sensitivity in Young and OldAlex G. Bien, MDUniversity of Nebraska Medical CenterOmaha, Nebraska

2003Evaluation of Biofilms in Chronic SinusitisJoel R. Perloff, MDUniversity of Pennsylvania Medical CenterPhiladelphia, PA

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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, USMichael Benninger, USBernard Blomfield, US*Max Bornstein, US*

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

DEfrain Davalos, MexicoH.A.E. van Dishoeck, 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*

93

Robert M. Hansen, US*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, CroatiaFrederick A. Kuhn, US

LClifford F. Lake, US*Donald Lanza, USDon Leopold, USWalter 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*

94

Carl B. Sputh, USHeinz Stammberger, AustriaAlbert Steiner, US*Sydney L. Stevens, US*Fred Stucke, USGiorgio Sulsenti, ItalyEdward A. Swartz, US

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

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

* Deceased

95

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

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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

97