Abstract
To propose a simple technique for preservation, medialization and stabilization of the middle turbinate through a planned medial synechiae formation using suction electrocautery between middle turbinate and nasal septum. Study design is Case series. 150 cases of chronic rhino sinusitis who underwent ESS were selected and stabilization of the middle turbinate through a planned medial synechiae formation using suction electrocautery was done as last step and results studied. Adequate medialization was achieved in 141 cases with 94% success rate. This technique of medialization of middle turbinate through a planned medial synechiae formation using cautery between middle turbinate and nasal septum is simple, quick to perform, do not require any special or costly instrument, do not require any special training and thus can be easily done by beginners also and most importantly with good success rate and surgery outcome.
Keywords: FESS, Middle turbinate, Complications of FESS
Introduction
Endoscopic sinus surgery has become the standard of care for the treatment of medically refractory chronic rhinosinusitis [1]. During the course of endoscopic sinus surgery however, it is not unusual for the mucosal surface of the middle turbinate to become traumatised [2].
The most frequently reported complication is adhesion of the lateral aspect of the middle turbinate to the lateral nasal wall [3, 4]. The potential sequela of turbinate lateralization and scarring is obstruction of the middle meatus and the maxillary, ethmoid, or frontal sinus ostia. This complication may contribute to a recurrence of sinus disease and perhaps necessitate revision surgery [1].
Various techniques are described to prevent middle turbinate lateralisation after sinus surgery. These include prophylactic partial turbinate resection [5], “controlled” synechiae formation [6, 7], and middle turbinate-septum clipping [8]. However, we do not advocate unnecessary resection or further trauma to an already fragile anatomic structure.
Our technique is simple and effective in prevention of middle turbinate lateralization, it involves making the two surfaces raw using cauterization and hence formation of synechiae medially.
Materials and Method
150 cases of chronic rhino sinusitis who underwent ESS are included in this study. Extent of surgery varied in patients depending on the disease extent. Patients of chronic rhinosinusitis with either concha bullosa or thin middle turbinate or middle turbinate with polypoid changes or cases in which medial and/or lateral fracture of medial turbinate was done during surgery making the normal middle turbinate floppy were included in this study. Rest all cases were excluded. Detailed history, anterior rhinoscopy, nasal endoscopy with CT Scan PNS were done preoperatively and patients underwent ESS which varied from conchoplasty to middle meatal antrostomy, anterior and posterior ethmoidectomy, frontal sinusotomy and sphenoidotomy. Once the ESS was done medialization of middle turbinate was done using insulated suction cautery tip. Raw areas is created at the tip of anteromedial part of middle turbinate (Fig. 1) and on the corresponding surface of the nasal septum (Fig. 2) and than both joined together and kept in place with a middle meatus pack for 2 days (Figs. 3 and 4). Septoplasty was also required in 28 cases, in which a piece of cartilage was repositioned at the site of cauterization to prevent septal perforation. Suction clearance was done on post op day 4 and 7 and when required. Follow up was done at 1, 3 and 6 month.
Fig. 1.
Raw area at the tip of anteromedial part of right middle turbinate
Fig. 2.
Raw area being created on the corresponding surface of the nasal septum
Fig. 3.
Both raw areas being opposed together
Fig. 4.
Opposed middle turbinate with septum intraoperative
Results
Out of 150 patients 92 were females and 58 males. Mean age of the patients were 33 years. 120 cases were bilateral and 30 unilateral. Synechiae was formed successfully between middle turbinate and nasal septum in 141 cases with success rate of 94% (Fig. 5).
Fig. 5.
Synechiae between middle turbinate and septum on follow up at 3 months
In the remaining 9 cases, mostly were in the initial part of the study in which middle turbinate was disturbed from its position in immediate post operative period during suction clearance or nasal packing. In these cases procedure was repeated with success.
Discussion
The most common complication of ESS, occurring in as many as 43% of patients, is lateralization of the middle turbinate [9, 10]. The formation of scar tissue between the middle turbinate and lateral nasal wall can obstruct the outflow of the ethmoid, maxillary and frontal sinuses, leading to recurrent symptoms and necessitating attempts of synechia division in the office or further surgery.
Proper handling of the middle turbinate and the prevention of lateralization appear to be the keys to avoiding postoperative problems and ensuring a successful outcome for the patient undergoing ESS [11].
However in certain situations in which disease involves the middle turbinate like concha bullosa, thin middle turbinate or middle turbinate with polypoid changes or cases in which medial and/or lateral fracture of medial turbinate was done during surgery making the normal middle turbinate floppy it becomes essential to do proper medialization of middle turbinate for success of the surgery.
Thus Several techniques in medializing the middle turbinate have been proposed. Shikani advocated meatal antrostomy stents in the maxillary natural ostium for 2 weeks until reepithialization occurred to keep the ostio meatal complex patent [12]. Moukarzel used a metallic clip on the head of the middle turbinate and the septum [8]. Thorton suggested suturing of the middle turbinate and septum for stabilization [13]. Bolger described planned medial synechia by abrading the middle turbinate and septum using a sickle knife and stabilizing the lateral side of the middle turbinate with packing [5]. Friedman furthered this idea, reporting excellent results using a microdebrider instead of a sickle knife [6].
In our opinion, osteo meatal complex stents and turbine septal metallic clips may cause foreign body reactions and further granulation, turbinate septal suturing seems quite a difficult and time consuming procedure suited best in experts hand; and sickle knife or microdebrider abrasion followed by nasal pack stabilization of the middle turbinate can cause imprecise apposition of the denuded surfaces. Synechiae formation on the posterior segment of the middle turbinate could lateralize the anterior segment, causing ostio meatal complex obstruction and recurrence of symptoms. Excessive nasal pack pressure could also medialize and cause synechiae of the entire medial segment of middle turbinate to the nasal septum, blocking airflow to the nasal roof leading to loss of smell [14].
Lindemann et al. [7] reported success rate of 85% using suture medialization procedure. Jae Yong Lee et al. [11] had success rate of 94% using silastic sheet. Our results are comparable with the previous studies with success rate of 94%.
An ideal medialization of the middle turbinate is optimally stabilized by planned small synechiae at its antero medial region leaving enough space at its antero superior and posterior regions for adequate air passage both for ventilation and proper smell. This technique of medialization of middle turbinate through a planned medial synechiae formation using cautery between middle turbinate and nasal septum is simple, quick to perform, do not require any special or costly instrument, do not require any special training and thus can be easily done by beginners also, do not disrupt the nasal anatomy any further and most importantly with good success rate and surgery outcome.
Conclusion
Choice of technique best depends on surgeons choice and expertise. This technique of middle turbinate medialization is simple, effective, quick with good results even in the hands of beginners.
Funding
There are no financial interests the authors may have in companies or other entities that have an interest in the information in the contribution (e.g., grants, advisory boards, employment, consultancies, contracts, honoraria, royalties, expert testimony, partnerships, or stock ownership in medically related fields). The authors have no financial interest.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
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