Abstract
Microdebrider is a modern powered instrument which is electrically driven with a shaver and a suction. The present study aims to assess the subjective and objective outcome in patients with sinonasal disease after microdebrider assisted endoscopic sinus surgery. A prospective observational study was carried out among 40 patients with symptoms suggestive of sinonasal diseases willing to undergo microdebrider assisted sinus surgery at our tertiary care hospital from January 2019 to December 2019. All the patients underwent microdebrider assisted endoscopic sinus surgery (ESS). Patients were subjectively evaluated using the Lund and Mackay staging system using visual analogue score and objectively using nasal endoscopy by the Lund and Kennedy scoring system preoperatively and post operatively after 6 weeks. 40 patients were included in the study. A mean age of 37 years were noted. All patients showed significant statistical improvement in Lund Mackay scoring system by visual analogue scoring and Lund Kennedy endoscopic scoring postoperatively. Thus, microdebrider offers a better therapeutic approach for patients with sinonasal diseases when compared to endoscopic surgery with the conventional instruments. The advantage of using microdebrider in ESS remains to be proper removal of the pathology, good surgical field and better postoperative outcome.
Keywords: Microdebrider, Sinonasal disease, Endoscopic sinus surgery
Introduction
The nose and the paranasal sinuses acts as a host for lot of conditions and diseases together called as sinonasal diseases. The broad spectrum of sinonasal pathology includes conditions such as chronic rhinosinusitis, antrochoanal polyp, ethmoidal polyposis with or without sinusitis, benign conditions like inverted papilloma, juvenile nasopharyngeal angiofibroma (JNA), mucocele of paranasal sinuses etc. [1].
Surgery for sinonasal disease is effective for those conditions with failed medical therapy. Functional endoscopic sinus surgery (FESS) is now the standard mode of treatment. Better absorption of medications and re-establishment of natural pathway of drainage remains to be the main aim of FESS [2].
The conventional instruments used in Endoscopic Sinus Surgery by their punching, tearing and stripping action creates a blood-filled surgical field with no mucosal preservation and scarring. Visibility of the operating area is the key to the safety of the FESS procedure, which can be compromised by bleeding. It can cause intraoperative complications, prolong the operating time and may result in incomplete surgery [3, 4].
Microdebrider is a modern multipurpose powered instrument which is electrically driven with a shaver and a suction. With the suction, tissue is sucked on one side and as the blade rotates the tissue is shredded between the cannulas.
Greatest advantage in using the microdebrider as the primary instrument in endoscopic sinus surgery (ESS) is that, with a single instrument multiple functions can be achieved, thereby providing advantage of limited working area in narrow nasal cavities having proximity to the skull base. Constant clearing of blood, tissue and bone fragments due to continuous integrated suction gives a proper visualization of the operative field thereby obviating the need to move in and out of the surgical field thereby reducing the operating duration [5].
The clinical outcome after microdebrider assisted surgery have not been assessed separately in previous studies. In general, microdebrider is considered safe for sinus surgery. So the present study aims to find out the subjective and objective outcome in patients with sinonasal disease after microdebrider assisted endoscopic sinus surgery.
Aim
The present study aims to find out the subjective and objective outcome in patients with sinonasal disease after microdebrider assisted endoscopic sinus surgery.
Methods
Study Design
A hospital based prospective observation study was carried out among patients with symptoms suggestive of sinonasal diseases willing to undergo microdebrider assisted endoscopic sinus surgery at our tertiary care hospital from January 2019 to December 2019.
Sample Size
40 patients with age group from 16–60 years were included.
Inclusion Criteria
Patients who had clinical and radiological features suggestive of sinonasal disease and who did not respond to conservative treatment and willing to undergo CT scan for evaluation and undergo surgical treatment were included in the study.
Exclusion Criteria
Patients with history of previous sinonasal surgeries and patients diagnosed or suspected of diseases like cystic fibrosis, primary ciliary dyskinesia, ciliary motility disorders, immunodeficiency were excluded from the study.
Methodology
A subjective evaluation of patients symptoms were done using the Lund and Mackay symptom staging system score by visual analogue scoring (VAS) method using values 0–10. Along with anterior rhinoscopy, endoscopic evaluation was performed and findings were noted according to recommendation given by Lund and Kennady endoscopic scoring. Visual analogue scoring (VAS) and endoscopic scoring were assessed and compared preoperatively and postoperatively after 6 weeks.
Postoperatively patient was followed up at 1 week and 6 weeks.
Ethical Clearance.
Institutional ethical clearance was obtained -MDC/DOME/42.
Result
Among the 40 patients of sinonasal disease studied, 14 patients (35%) had Chronic Rhinosinusitis, 14 patients (35%) had Ethmoidal Polyposis, 5 patients(12.5%) had Fungal Rhinosinusitis, 4 patients (10%) had JNA, and 3 patients(7.5%) had Sinonasal mass (Figure 1). The mean age group among the sample was 37 years among which 22 were male and 18 were female.
Fig. 1.
Diagnosis wise distribution of patients
A mean total pretest Lund Mackay VAS score of 35.83 was noted preoperatively among all the sinonasal disease which improved to 9.05 post operatively with a significant p value. A mean total pretest Lund Kennedy endoscopic score of 5.10 was noted preoperatively among all the sinonasal diseases which improved to 2.0 post operatively with a significant p value.
Statistically significant improvement was seen in the both VAS and Lund Kennedy endoscopic scoring system after surgery.
Among the sinonasal disease in our study, the nasal polyp group showed highest improvement postoperatively in terms of both visual analogue scoring and Lund Kennedy endoscopic scoring as seen in Table 1 and 2
Table 1.
Comparison of pre-test and post-test VAS scores in 5 diagnoses by Wilcoxon matched pairs test
| Samples | Time | Mean | Std. Dv | p-value |
|---|---|---|---|---|
| Total | Pretest | 35.83 | 5.36 | 0.0001* |
| Posttest | 9.05 | 2.40 | ||
| Chronic rhinosinusitis | Pretest | 35.71 | 6.09 | 0.0010* |
| Posttest | 8.79 | 2.52 | ||
| Ethmoidal polyposis | Pretest | 37.86 | 4.54 | 0.0010* |
| Posttest | 8.36 | 1.98 | ||
| Fungal rhinosinusitis | Pretest | 35.20 | 2.28 | 0.0431* |
| Posttest | 11.40 | 1.14 | ||
| JNA | Pretest | 30.25 | 6.55 | 0.0679 |
| Posttest | 7.25 | 1.26 | ||
| Sinonasal mass | Pretest | 35.33 | 4.16 | 0.1088 |
| Posttest | 12.00 | 1.73 |
Table 2.
Comparison of pretest and posttest Lund and Kennedy scores in sinonasal diseases by Wilcoxon matched pairs test
| Samples | Time | Mean | Std. Dv | p-value |
|---|---|---|---|---|
| Total | Pretest | 5.10 | 2.17 | 0.0001* |
| Posttest | 2.00 | 0.82 | ||
| Chronic rhinosinusitis | Pretest | 3.50 | 1.56 | 0.0015* |
| Posttest | 1.79 | 0.80 | ||
| Ethmoidal polyposis | Pretest | 7.14 | 1.61 | 0.0010* |
| Posttest | 2.57 | 0.65 | ||
| Fungal rhinosinusitis | Pretest | 4.00 | 1.73 | 0.0431* |
| Posttest | 1.20 | 0.45 | ||
| JNA | Pretest | 5.25 | 0.96 | 0.0679 |
| Posttest | 2.00 | 0.00 | ||
| Sinonasal mass | Pretest | 4.67 | 1.15 | 0.1088 |
| Posttest | 1.67 | 1.15 |
Discussion
Sinonasal diseases has a wide range of pathology which includes inflammatory and infective etiology. Chronic rhinosinusitis, antrochoanal polyp, ethmoidal polyposis with or without sinusitis, benign conditions like inverted papilloma, juvenile nasopharyngeal angiofibroma, mucocele of paranasal sinuses etc. are few commonly encountered conditions.
Endoscopic sinus surgery was designed initially for treatment of polyps and rhinosinusitis. Later it has been extended to several other conditions. Endoscopic sinus surgery is the surgery recommended that involves anterior to posterior approach designed to achieve functional intact sinus with minimal surgical intervention necessary. The main aim of this procedure is to eliminate the disease in the sinus region to promote normal physiology by a conservative procedure thereby the name functional.
The keystone of this technique is to perform endoscopically minimal procedure as well as to preserve mucosa. FESS requires careful attention for preservation of mucosa during surgery and postoperative follow-up is required. Serious complications of ESS are rare but proper counselling should be done [6].
Conventional instruments were holding an indomitable place in rhinological surgeries. But now with improvement in medical technology, powered instruments have started changing the trend and is becoming really popular when compared to forceps and curettes.
Microdebrider is a modern multipurpose instrument which is electrically driven with a shaver and a suction. With the suction, tissue is sucked on one side and as the blade rotates the tissue which is shredded between the cannulas. Hence present study is aimed to find out the subjective and objective outcome of microdebrider in various sinonasal diseses.
In the present study out of 40 patients of the sinonasal disease observed, 55% were male and 45% were female patients. The mean age group among the sinonasal group was observed to be 37.45 years with youngest being 13 years and oldest being 60 years.
A mean total pretest Lund Mackay VAS score of 35.83 was noted preoperatively among all the sinonasal disease which improved to 9.05 post operatively with a significant p value. Statistically significant improvement in VAS scores was noted in patients in Chronic rhinosinusitis group, Ethmoidal Polyposis group and Fungal rhinosinusitis group with a p value of 0.01, 0.01 and 0.04 respectively. No improvement (p > 0.05) was observed in JNA and Sinonasal mass group (Table 1). A study done by Bellad SA et al. (2019) [7] showed significant VAS score improvement post operatively by using powered instrument comparatively to regular instruments in treating sinonasal polyposis.
A mean total pretest Lund Kennedy endoscopic score of 5.10 was noted preoperatively among all the sinonasal diseases which improved to 2.0 post operatively with a significant p value. (Table 2).
As per analysis between the sinonasal disease it was noted that microdebrider treatment had better improvement (p = 0.03) in Lund kennady scores in treatment of ethmoidal polyposis when compared to fungal rhinosinusitus. There was also significant improvement (p < 0.05) in Lund kennady scores in treating chronic rhinosinusitus when compared to ethmoidal polyposi, JNA and sinonasal mass.
In a study by Bindia Ghera et al. (2016) [3], microdebriders are effective than conventional technique due to less bleeding(relatively bloodless) and less surgical time, better postoperative scores.
In a study conducted by Krouse et al. (1996) [8], microdebrider demonstrated faster healing, decreased bleeding and ostial reocclusion when compared to standard techniques.
Singh R et al. (2011) [9] in their study found no statistically significance in surgical outcome for patients when microdebrider was compared with conventional instruments but symptomatically improved in patients for whom microdebrider was used.
Mohanakarthikeyen et al. (2017) [10] in their study concluded that microdebrider offers profound advantage over the use of standard techniques with regards to decreased bleeding, safety and improved result.
One of the most important complications following sinus surgery is formation of synechiae with 6 to 27% chances. During the healing mucosa which is denuded come in contact and synechiae is formed. Synechiae is formed due to trauma by the backbiter and/or by stripping of the mucosa. A microdebrider offers minimal tissue trauma and preserve normal mucosa thereby avoiding excessive scarring [11].
Conclusion
The use of microdebrider in endoscopic sinus surgery has the advantage of complete clearance of disease, smoother intra operative course and better post operative healing. The use and clinical outcome of microdebrider in different sinonasal diseases have not be assessed extensively. In the present study the subjective and objective outcome of microdebrider in different sinonasal diseases have been assessed and significant improvement has been noted postoperatively.
Compliance with Ethical Standards
Conflict of interest
All authors declare that they has no conflict of interest.
Ethical Approval
We agree that our study is ethical and compliant with ethical standards. Institutional ethical clearance obtained—MDC/DOME/42. 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.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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