Bhasin 1

Armaan Bhasin
Mrs. Bagley
Intern/Mentor GT
26 October 2017
Annotated Source List

American Academy of Otolaryngology- Head and Neck Surgery. 2017, www.entnet.org/.

Accessed 8 Oct. 2017.

This association represents otolaryngologists and their work worldwide. The website
includes news regarding the ear, nose, throat (ENT) field, which serves useful in finding
potential interest in topics that are relevant to present day. There are also listed practice
guidelines that help establish understanding the mechanics of the field. Another key component
to the association website is its AcademyU educational resource. It provides several self-
assessments and resources like online lectures with the goal of providing greater basis on
otolaryngology. There are also ebooks and ecourses in the AcademyU that could provide context
for understanding more complex topics of research. There are several filters giving sources that
can vary from all interests of otolaryngology from general to head and neck surgery to sleep
medicine. Additionally, it provides support to find a specialized doctor near you and
guaranteeing practice management for patients.
The association website serves as an excellent resource, as it serves in supplying a wide
scope of information regarding otolaryngology. Not only does the academy provide general up to
date information towards the field, it holds strong as a wealth of information to strengthen
understanding required as the research project becomes more specific. I will be able to revisit
and continually educate myself on topics that I hear through my mentorship and the topic that
could draw interest.

Beningfield, Alec, Dr. Interview. 5 Oct. 2017.

Dr. Beningfield, my mentor, currently works at ENTAA care as a physician and surgeon
for his patients for over the past six years. He was an engineer for 8 years before studying
otolaryngology at the University of Kansas School of Medicine. Following medical school he
completed his General Surgery internship and residency before spending 4 years in the United
States Air Force as an active otolaryngologist. He is a fellow for the American Academy of
Otolaryngology- Neck and Head Surgery and board certified by American Board of
Otolaryngology. He stands as a partner of the private practice ENTAA care while actively
performing surgery and consultations with patients along with his other colleagues.

Chaaban, Mohamad R. et al. “Cystic Fibrosis Chronic Rhinosinusitis: A Comprehensive

Review.” American Journal of Rhinology & Allergy 27.5 (2013): 387–395. PMC. Web.
17 Oct. 2017.

In a collaborative review, the authors create an in-depth explanation using over 100
studies and pertaining sources of cystic fibrosis (CF) and chronic rhinosinusitis (CRS). The
authors begin the review with a detailed background on cystic fibrosis as a lethal disease and the
advancements made toward prolonging the life of its patients from teenager life expectancy to in
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their mid 30s. The authors focus on the pertinent means and effects of cystic fibrosis on quality
of life from sinus issues. The journal article makes use of sophisticated description of the specific
genetic mutations that occur in the CFTR gene, resulting in the inaccurate formation of proteins.
More interestingly, the authors summarize the quantity and quality of existing studies to the topic
by naming a specific treatment type such as topical nasal saline irrigation or FESS surgery and
its effect on patients’ quality of living.
A key aspect to be journal article is the details it provides on the pathophysiology of
chronic rhinosinusitis and systems connected that arise from cystic fibrosis. The mucociliary
clearance is responsible for the defense against disease by moving inhaled particles to the
digestive tract, but the mutation of the CFTR gene results in alteration of movement of across the
epithelium, severely impairing the mucociliary clearance. This subsequently creates very thick
mucus that can harbor growing bacteria. The condition is very relevant to cystic fibrosis as
nearly all patients also have high incidence of CRS. Congested sinuses can also become a living
space for infections that recurringly affects the lungs. Fungal growth can also be a problem
causing allergic fungal rhinosinusitis, treatable with inhaled steroids.
The article then briefly elaborates on the symptoms of CRS and recognition with the use
of observing the abnormalities in imaging of the sinuses before moving towards the treatment
and management of CRS. Various treatments are listed the gone into in detail pertaining the
efficacy, usage, and research on the area. Although most medical treatments such as antibiotics
have generally positive effects, there lacks enough research in the area to further strengthen the
claims made. An interesting side of treatment that is looked at is the use of therapeutic, which
would target the mutant protein that is causing the problem. Several drugs are looked into such
as ivacaftor for their effect of sinuses and cystic fibrosis as a whole. Cell surface was replenished
in the proteins, so the author assumes that the new treatment would rejuvenate the mucociliary
clearance, increasing function.
The article then goes into the surgical approach and its experience with sinus disease.
Surgery is usually the second choice treatment after medical treatments do not work. Studies
have shown that the surgery, removing some or all of the sinuses, helps to control the buildup on
pulmonary infection in the sinuses, hopefully bringing the patient better lung lifespan. The usage
of functional endoscopic sinus surgery (FESS) does however main controversial with conflicting
evidence. There does appear to be an increase in quality of life and endoscopic improvement
after the surgery, but there still poses a high rate of revision surgery ranging from 13% to 89% in
several of the author’s sources. Some patients also display similar or worse radiographic
abnormalities even after the FESS. Children seem to display a less receptive effect from the
surgery. There also lays the possibility of the sinuses refilling, but the main goal of treatment
does remain creating access for the sinuses to drain.
The following article will serve vital to my research as the authors do a superb job in
laying out all the concepts and findings in an understandable but detailed manner. Although the
article does make references to the need for greater research, it makes strong use of the multitude
of sources available in the field to present in an omniscient format. The credibility of multiple
doctors writing the review as well as over 4 pages of consulted source proves strong. The article
does go into too much technicality over the genetics behind cystic fibrosis but quickly moves
forward into the in-depth content of treatment, symptoms, and results that provide a lot of
insight.
ENTAA Care. 2017, www.entaacare.com/. Accessed 8 Oct. 2017.
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The ENTAA care website gives overview and specifics for their practice. The home page
details the varying services of the offers from ear nose throat procedures and checkups to allergy
related ones and audiology. For each area, the website provides a detailed list of the potential
problems and parts of the body that are affected. For example, one can click read more for ENT
to find more about obstructive sleep apnea, such as its symptoms, diagnosis, and treatment. The
main sections for ENT Services include Ear Nose Throat, Balance, Voice and Swallowing
Center, and Sleep and Snoring, giving an abundance of resources to patients and myself. Under
the About Us tab, there is detailed description of the doctors that work for ENTAA care. The
website is made for ease of patients with quick access to hours, visitations, and a patient portal.
This website will remain significant for me because it provides background for the
people I will interact and learn from on a daily basis. The About Us tab will also serve as a great
list of potential interviewees in the area of otolaryngology. I find that the website lays out the
separate topics of the field well and that the in the long run give through understanding for
greater depth.

Hamburger, Marc, Dr. Interview. 5 Oct. 2017.

Dr. Hamburger, one of my mentor’s colleagues, works at ENTAA care. Hamburger

received his medical degree with cum laude from University of Maryland School of Medicine.
Afterwards, he trained for internal medicine at University of Rochester, followed by general
surgery internship at the University of Maryland as well as Otolaryngology – Head and Neck
Surgery residency. He is also board certified and a member of the American Academy of
Otolaryngology – Head and Neck Surgery. As well as working for ENTAA care, Hamburger is
the Chairman of the Division of Otolaryngology at Howard County General Hospital, overall an
excellent resource for in depth topics of otolaryngology.

Henig, Noreen. “Sinusitis and Cystic Fibrosis.” Cystic Fibrosis Center at Stanford, 2009,
web.stanford.edu/group/cfcenter/CFNews-Sinusitis.html. Accessed 17 Oct. 2017.

Dr. Noreen’s article helps develop the connection between cystic fibrosis and sinusitis.
Cystic fibrosis predominantly affects the lungs or the lower respiratory tract. The source outlines
the fact that the “upper respiratory tract” (the sinuses) and lower respiratory tract (lungs) have a
layer of epithelium. She delves into the symptoms that cystic fibrosis patients often experience
with their sinuses, characterized with chronic discharge to nasal obstruction and headaches.
Cystic fibrosis also is distinguished by its physical distinction of nasal polyps, which are extra
tissue mass in the nose that could cause problems. Dr. Noreen also details on how to physically
differentiate cystic fibrosis related sinusitis from various imaging taken such as computed
tomography. Diagnosis comes from the synergy of reported symptoms and studied imaging.
Sinus disease for cystic fibrosis patients remains a chronic issue that can be handled through
various means of treatment. The main types of treatment include antibiotics, nasal steroids,
mechanical clearance with nasal flushes, antihistamines and decongestants, and surgical
intervention. Most treatment not specifically investigated in for cystic fibrosis, there is not
necessarily a best option. Antibiotics usually take a longer time because of decreased ability to
penetrate and clear the sinuses. Nasal flushes provide relief and could potentially remove
infectious pathogens. Nasal steroid take significant time but are seen to reduce polyps size.
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Surgical approach is used for patients with more ongoing issues and improves sinus access, in
turn relieving obstruction, nasal discharge, and increased ability to smell.
The article helped develop basis understanding of cystic fibrosis’ relationship to the area
of my studied field. Dr. Noreen is not only a staff member of the cystic fibrosis center at
Stanford but holds a doctorate degree and cited all her sources on the page, establishing her
credibility on the subject. The article helps to bring up other methods of treatment that can be
factored into the decision of looking at the efficacy of functional endoscopic sinus surgery
(FESS). Overall the article provides a great list of potential sources to visit, details into the
background of sinusitis in CF patients, and offers another perspective in looking at the
effectiveness of cystic fibrosis sinus surgery as a well as its application.

Mackay, I S, and B Djazaeri. “Chronic Sinusitis in Cystic Fibrosis.” Journal of the Royal Society
of Medicine 87.Suppl 21 (1994): 17–19. Print.

The following journal article details into chronic sinusitis pertaining to cystic fibrosis.
Chronic rhinosinusitis develops from chronic infection, and this brings inflammation and excess
of fluid of inconsistent viscosity of the mucous membrane of the nose, paranasal sinuses, and
lining of the ethmoidal sinuses. Along with cystic fibrosis, which commonly results in chronic
sinusitis in children, primary ciliary dyskinesia, which comes from abnormality in the ciliary
motility, is an important potential cause to consider. Nasal polyps in children is an immediate
indicator to be wary of cystic fibrosis because of its rarity in kids. Scans and images of the
sinuses can give an indication of cystic fibrosis not only from the polyps but also frontal sinuses
that are small and underdeveloped. This leads to the figure that one third of cystic fibrosis
patients with unnoticable front sinuses in imaging, observable in the wide gap of frontal sinus
dimensions between patients with or without cystic fibrosis. Doctors use CT scans to be able to
observe sinuses to look for thickening of the sinus lining and increased bone density from
chronic osteitis and broadening of ostio-meatal area.
Looking deeper at rhinosinus treatment, the first treatments begin with medical
approaches because doctors like to reserve surgery if not needed.This brings antibiotics and
topical anti inflammatories. Topical corticosteroids (steroids that work like adrenal glands) are
seen as effective but also should not be used long term for children because they are to a small
degree absorbed by the body, having its steroid related effects. Another drawback to consider
with antibiotics could be that certain organisms that grow more rampantly in cystic fibrosis
patients such as Pseudomonas aeruginosa is that long term treatment for the respiratory tracts
causes antibiotic resistance and comes with the complexity of each patient requiring
individualized treatment because of varying sensitivity and organism. Looking at the
effectiveness through survey data of several (n=46) patients who had nasal polyps showed that
about one third of patients did not have symptoms involved, about one fourth of patients
underwent surgery, and the remaining portion was treated using topical steroids alone, which
could attest to medications effectiveness as a whole. Surgery is still a high value, but this does
display there are more options to factor in.
Now when the clinical approach does not work, doctors move towards surgery option.
FESS aims to restore the natural mucociliary clearance mechanism, drainage as possible. To take
a look at effectiveness of FESS, the article delves into an audit of FESS surgery patients. When
considering the data holistically, 85.59% of people had considered themselves asymptomatic or
improved. The data does display some opposing trends. As time goes on patients have lower
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patient symptoms scored that subjective to patient assessment, but at the time, over the two year
span the percentage of people who have the same condition as before grows from 31% of people
at 6 months post operation to 50% at 24 months post operation. FESS provides a minimally
invasive approach that has similar effects to surgeries that are more aggressive, but there exists a
large gap in efficacy between CF patients and non CF patients of the procedure.
Rhinosinusitis is prevalent in 100% of CF patients because radiological imaging (CT)
would show the changes and differences in the patients of CF. The reason to be dealing with the
upper respiratory tract even though cystic fibrosis is a problem of the lower tract is that
prevention of the upper tract helps with controlling lower tract infection, which is significant
with the prevalence of heart-lung transplants.
This article helped me to focus into at chronic sinusitis that comes with cystic fibrosis
and a deeper look at treatment efficacy with data. To understand the topic as a whole, I need the
preface to subject. The article provides good background to the sinus sie to cystic fibrosis, giving
me a better comprehension of the what it looks like in patients and how it is distinguished. When
considering treatments that will be pertinent to my research paper, the article helps to distinguish
potential advantages and disadvantages that come with medical approach to CRS because it is
important to consider the alternatives and its efficacy to truly consider the efficacy and need for
FESS. Although there remains some statistical alarm from a lack of survey participants, this may
stem from having a small affected population; however, the data does provide me with an
important consideration that there may be a lack of strongly consistent long term approach to the
issue.

Patel, Mira A. et al. “Tobacco Smoke Exposure and Eustachian Tube Disorders in US Children
and Adolescents.” Ed. Cheryl S. Rosenfeld. PLoS ONE 11.10 (2016): e0163926. PMC.
Web. 8 Oct. 2017.

The journal study discusses the effect of secondhand smoke on the prevalence of
Eustachian tube dysfunction in children. The study used tympanometry measurements, or a
device that would change the air pressure of the ear to indicate if one has Eustachian tube
dysfunction, as the basis of screening. They also collected general information of the participants
and made sure to check their cotinine levels, which assesses the environmental tobacco smoke
exposure of the participants. The study found that elevated serum cotinine levels, found in those
experiencing second hand smoke, does lead to increases of Eustachian tube dysfunction (ETD).
Error could come from the fact that being male, obese, having higher prevalence of sinus
problems, and those with a cold or earache in the past 24 hours had higher chances for ETD.
The article does not seem very helpful other than the fact that it provides some basis and
understanding of relationships of the sinus system. The topic seems obsolete to other topics of
the otolaryngology field but does help to narrow my research towards other areas.

Rosbe, Kristina W., et al. “Endoscopic Sinus Surgery in Cystic Fibrosis: Do Patients Benefit
from Surgery?” International Journal of Pediatric Otorhinolaryngology, no. 61, 2001,
pp. 113-19.
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The following journal article looks into many endoscopic sinus surgery studies while also
developing its own study on quantitative hospital data for cystic fibrosis patients. The authors
make the point that the surgery is referred to without the “functional” aspect because there is no
difference in most patients pre- and postoperative in CT scans even if there is reduced symptoms.
The surgery’s purpose has shifted to remove polypoid disease and irrigate nasal secretion that
would decrease the bacterial load, instead of fixing the function of the nasal sinuses.
The study was conducted with 66 CF children patients with the exclusion of lung
transplant patients as well as those with multiple surgeries in less than 6 months for a sufficient
study time for pre- and postop. Their study had 38% of patients who underwent an additional
procedure. CF patients often need nasal or oral steroids for sinusitis, so the researchers looked at
the rate of steroid usage before and after the operation. Although there were some patients who
were taken off nasal steroids, some were also put on them, so there was no statistically
significant differences in steroid usage. Also, pulmonary function tests were administered prior
to and after the operation because pulmonary function of CF patients is reduced and an important
area to look at for improvement; however, there were also no statistically significant difference
in the tests observed, meaning the procedure may not do much for patients except for symptom
relief. The article did highlight one area of improvement: patient hospital days. After the surgery
there was a mean 9.5 day reduction in hospital days, suggesting that ESS could be cost saving
and improve the quality of life for patients who do not have to go as often to the hospital or miss
school as much.
The article also highlights key points about ESS for CF patients from other studies. The
indicators for surgical intervention for chronic sinusitis are controversial and varied between
clinicians, which may pose a problem in identifying improvement or results, but clinicians agree
that polyps should be addressed with ESS. Although nasal steroids may still be necessary, there
is consensus that postoperative there is a decrease in steroid requirement, hospital admission, and
exercise tolerance, which could be considered quality of life improvement aspects. Decreasing
symptoms is a benefit to ESS, but there is never complete eradication of the sinusitis condition.
One study the author cites reports that all CF patients for ESS in their study had recurrence of
polyposis within 18 months which may bring efficacy the argument.
When looking at the merit of the article, the article has a strong set of cited sources,
which increase the credibility with which the authors write as well as provide a wealth of sources
that can be checked for information pertaining the surgery and CF. The article does identify
potential areas of error in the study that are present in most studies have been looked at because
there is a small sample size that is performed on by an assortment of surgeons which could result
in variance between each one. There seems to be a general need for a larger scale study on the
topic, but the following article does a good job at providing the results in manageable tables and
digressing the results into understand contexts. Heavy use of abbreviations does make the article
somewhat confusing in having to look back at each one, but the information presented is of high
quantitative nature that can be useful compared to the qualitative symptom survey from patients
found in other studies and journals.

Slack, Robert, and Grant Bates. “Functional Endoscopic Sinus Surgery.” Am Fam Physician, vol.
58, no. 3, 1 Sept. 1998, pp. 707-18.

The following journal feature article pertains to functional endoscopic sinus surgery
(FESS) in a broad sense. Since FESS is used after other medical treatments have failed, 90% of
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symptoms of patients suffering chronic infective sinusitis are improved postop. Looking at the
pathophysiology of sinusitis, the four sinuses (frontal, above the eyes; maxillary, under the eyes;
ethmoid, between the eyes; sphenoid, behind the eyes) function optimally and fight infection
with proper ventilation of the sinuses to the ostia, the openings to the nose. When CRS flares up,
cilia function decreases, causing mucus to build up in the sinuses. This in turn closes the ostia
opening and creates an ideal condition of bacterial infection from mucus stasis.
FESS is preferred to conventional sinus surgery because it is minimally invasive with
similar results. Conventional surgery would require greater number of incisions and would
therefore leave scars and significant bruising and discomfort because it involves the removal of
the mucosa of the sinuses. FESS works at solving the problem through fixing the blockage of the
ostia through surgery to create a more ideal opening, based on the patient’s CT scan.
There is an 80-90% postop success rate of the procedure, but there are some potential
complications of FESS. Cerebrospinal fluid leaks are the most common complication, occurring
in 0.2 percent of patients, but it is a simple fix that can be observed and fixed during the
operation. There could also be less seriously hematoma and nasolacrimal duct stenosis, or more
seriously but very rarely, optic nerve damage that leads to blindness. Overall complication rate is
low at 0.44 percent, compared to the higher 1.4 percent for conventional sinus surgery.
To fully compose my research, I would need to understand the procedure that I am
researching as well. The following article helps me understand what the specifics for selection
for the usage of the procedure are and also goes into the pathophysiology of the broad conditions
used. Using the connections of CRS in cystic fibrosis and understanding the procedure’s methods
and aims, the article allows me to translate the cystic fibrosis sinusitis knowledge and evidence
with the greater depth on the procedure that this article provides, allowing me to correlate the
potential shortcoming of the long term use of the procedure in cystic patients to be from the cilial
function, not the anatomical fix specifically aimed at from the procedure. Most articles have not
looked at complications of the procedure itself, so this article proves useful to my research in
giving some postop conditions to consider. The article did include some extended uses of the
procedure that were not very significant to my topic so they were not discussed above.

Tumin, Dmitry, et al. “Safety of Endoscopic Sinus Surgery in Children with Cystic Fibrosis.”
International Journal of Pediatric Otorhinolaryngology, no. 98, 21 Apr. 2017, pp. 25-28.

Tumin et al offer a comprehensive look at the safety and complication of ESS,

interchangeable with FESS, in children with cystic fibrosis. The article introduces the condition
and some symptoms before going into some surgical considerations. The following study took
data from the American College of Surgeons’ National Surgical Quality to look at patients with
and without Cf who underwent ESS. There was a total of 821 patient data used for non-CF study
and 213 patients for CF study. The researchers compiled and aggregated the results into a
convenient table that compares CF and non-CF patients side by side. One surprising statistic to
keep in mind for the research project would be that 30% of CF patients stay at the hospital for
more than one day, but this remains minute because CF patients have a readmission rate of about
6% while non CF patients have a readmission rate of about 4%. High percentages of extended
stay at the hospital can be possibly explained through the need to watch anesthesiology and use
of intravenous antibiotics that can help in synergy with the surgery. The two values for
readmission prove to be very similar to each other that could suggest that there is equal rate of
potential issue regardless of presence of CF. This is significant because now in comparing the
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complication rates as a whole, the complications of the surgery in general can be analyzed
instead of focusing solely on those of cystic fibrosis because there is seems to be no major
complications between CF and and broader pediatric population.
Although there is a relatively low sample size for CF patients, this arises from the fact
that there is a limited CF population in general; however, this may cause the source to not to be
completely representative for the whole population affected by CF undergoing ESS. The authors
did not consider readmission for CF patients as a complication for the procedure because the
nature of CF causes the progress of the sinusitis. Revision surgery could be a potential viewpoint
in the argument of the efficacy of the procedure because patients may inevitably need revision.
Additionally the article discusses other forms of more aggressive modern treatment that could be
a more long term solution that may avoid revision such as modified endoscopic medial
maxillectomy.
Tumin et al present a study that attests to the multifacet nature of ESS for CF. The article
should prove moderately useful for my research because it does provide quantitative analysis of
CF ESS. Although it does not look at the effects of ESS on CF patients as much, the article
creates an updated examination of the safety of the procedure, which is crucial to consider in its
overall efficacy and usage. The article stays very concise on the topic at hand and makes data
easily interpretable for readers. The fact that the article introduces the concept of inevitable
progression of CF causing revision surgery plays an important viewpoint to factor when looking
at the drawbacks.

Vlastarakos, Petros V., et al. “Functional Endoscopic Sinus Surgery Improves Sinus-Related
Symptoms and Quality of Life in Children with Chronic Rhinosinusitis: A Systematic
Analysis and Meta-Analysis of Published Interventional Studies.” Clinical Pediatrics,
vol. 52, no. 12, 21 Oct. 2013, pp. 1091-97.

Vlastarakos et al’s article takes an important look at the quality of life of children
undergoing FESS for chronic rhinosinusitis, the condition that very frequently accompanies
cystic fibrosis. The authors of the article made use of the resources available in a compilation of
over twenty studies. ENT surgeons are reserved with FESS use with children because the same
procedure does not exactly apply for the smaller patient anatomy of a child. Looking at the main
remarks from the studies that the article looks into, there is a wealth of information that is not
even the focus presentation of the article in a table. Although revision may be a possibly for
some patients, this should not be undermined by the fact that the procedure has been reported to
have long term improvements in quality of life for children who have been facing symptoms for
an extended period of time. This promotes a positive impact on the patient and her family
because patients often see a “radical change in their lives” (pg. 1093). The author’s key remarks
for CF patients in the studies however is more varied because although CF patients have a 100%
improvement of their symptoms postoperative, 83% of children that are operated on end up
requiring a revision surgery 3-5 years after the first one. The surgery has a very high percentage
of major symptom improvement but displays a much lower chance of cure. FESS plays an
important role in providing the patients a better ability to clear infection on their own, resulting
in fewer infections. Reducing sinus infection connects to the lungs, potentially offering lower
pulmonary infection as well. FESS is reported to produce a positive change in the occurrences of
nasal congestion, purulent nasal discharge, and postnasal drainage postoperatively. The
distinction between FESS efficacy for CF patients merely lies in the limited period of time for
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which symptoms are relieved and quality of life increases compared to other healthy children.
Massive polyposis from CF does stand as a condition that needs to be addressed with FESS
though, so some conditions may not be resolvable for patients through traditional medical
treatment, bringing up the use of a reasonable alternative, FESS. Because of research on animals,
there is fear that FESS surgery could cause complications to the growth of facial structures of the
developing children; despite that, the article points to a human study (n=12 may be questionable)
that concluded that after a follow up 13.2 years later, children had no statistical significance in
facial growth differences. That does still stand as a potential concern to address in the overall
evaluation of FESS on CF.
The article was particularly advantageous for me. As a high school student, I have a
limited access to the studies and journals that I would otherwise have wanted to incorporate into
my research. The following article makes use of a strong array of journal article pertaining to the
subject and conveniently places the key points and remarks within the article, allowing me to
access a greater wealth of knowledge for my research that otherwise may not have been found.
The following article is able to put a quantitative look at the revision surgery percentage and time
frame that are important indicators to the efficacy of the procedure. The article seems to be in
unison with the other sources in that revision may be necessary, so the article helps me focus my
research paper because I will have to acknowledge that revision rate may not be paramount in
looking at FESS particularly for CF.