Abstract
The main goals of endoscopic sinus surgery (ESS) is, to enlarge the sinus ostia. Most common cause of failure of ESS is lateralization of the middle turbinate causing recurrent blockade of osteomeatal complex (OMC) and recurrence of disease. Many techniques have been described for preventing lateralization of the middle turbinate. We compared the postoperative outcomes following endoscopic sinus surgery (ESS) for sinonasal polyposis (SNP) with medialization suturing of middle turbinate and partial middle turbinectomy. 60 patients who underwent ESS for SNP were divided into three groups, Group A (Medialization suturing of the middle turbinate with septum), Group B (partial middle turbinectomy) and Group C (control-no middle turbinate intervention). Preoperative Lund Kennedy scoring, Lund McKay scoring, SNOT 22 scoring was done. Post-operatively, Lund Kennedy scoring was done at 1st, 4th, 12th week and SNOT 22 scoring was done at 4th, 12th week. Statistical analysis and comparison of data between the groups was done. Both the techniques, helped to improve OMC patency, mucosal healing, and to minimize adhesions. Medialization of the middle turbinate helped in improvement of SNOT 22 and Lund Kennedy scores in the postoperative period as compared to the non-interventional group. However, between the two middle turbinate interventional groups there was no statistically significant difference. Achieving middle meatal patency by middle turbinate interventions improves the postoperative outcomes. However, long-term follow-up studies are recommended for evaluation of efficacy of these techniques and to look for recurrence of disease in SNP.
Keywords: Endoscopic sinus surgery, Middle turbinate interventions, Medialization suturing of middle turbinate, Partial middle turbinectomy, Sinonasal polyposis
Introduction
Sinonasal polyps (SNP) arise from the edematous and prolapsed mucosal lining of the nose and the paranasal sinus [1]. Several modalities of treatment have been suggested for SNP depending on the extent of the disease, ranging from conservative management with topical corticosteroids to surgical interventions [2].
Most patients can be managed with pharmacological therapy. Some patients however do not respond despite appropriate medical therapy. In those patients who have persistent osteomeatal disease, Endoscopic Sinus Surgery (ESS) is the treatment modality.
The main goals of ESS are to enlarge the sinus ostia for maintenance of sufficient drainage and ventilation for all paranasal sinuses, to improve the visualization and topical drug delivery into sinuses [3]. It provides wide access for facilitation of postoperative care such as endoscopic examination and toileting of sinuses. Early recognition and management of local pathologies during the post-operative period are possible when the ostium is wide.
One of the most common adverse effect of ESS is lateralization of the middle turbinate (MT). It can occur due to the manipulation of the middle turbinate during surgery which can result in an unstable MT. Also, it is not unusual for the mucosal surface of the MT to get traumatized and cause synechiae between the turbinate and the lateral wall thus compromising the osteomeatal complex. A combination of all these factors predisposes the MT to lateralize which will lead to outflow tract obstruction and ultimately will require additional surgery due to recurrence of disease.
Various techniques like partial turbinate resection, controlled synechiae formation, middle turbinate-septum clipping, turbinate-septal suturing, and placement of stents and spacers are described to achieve and maintain patency of the middle meatus during ESS.
This study compares two different techniques used for achieving middle meatal patency (Septal- middle turbinate medialization suturing and Partial middle turbinectomy) and has compared postoperative outcomes in these techniques with that of non-interventional group.
Materials and Methods
This is a prospective study, conducted in the Department of Otorhinolaryngology in a tertiary care center from October 2018 to October 2020. All patients who underwent ESS for SNP during the study period, who were above 18 years of age and who consented to participate in the study were included. Patients with uncontrolled diabetes mellitus or hypertension, who had undergone previous sinus surgery, invasive fungal sinusitis and granulomatous diseases were excluded. Study comprised of 60 patients diagnosed with SNP and planned for ESS. These 60 patients were divided into three groups.
Group A—patients undergoing Septal-middle turbinate medialization suturing on both sides.
Group B—patients undergoing partial middle turbinectomy on both sides.
Group C—(control) no medialization suturing or partial turbinectomy.
Based on the preoperative endoscopic findings, the severity of the disease was calculated using Lund Kennedy scoring [4]. Preoperative severity of the disease on the CT scan was calculated using Lund McKay grading [5]. Quality of life was assessed using Sino-Nasal Outcome Test (SNOT-22).
Every 1st and 2nd patient undergoing ESS for SNP were subjected to middle turbinate interventions (1st patient—septal middle turbinate suturing, 2nd patient—partial middle turbinectomy). For every third patient, middle turbinate intervention was not done.
The steps of ESS—middle meatal antrostomy, uncinetomy, anterior and posterior ethmoidectomy, sphenoidectomy was done according to the extent of disease as found justified by the operating surgeon. Any gross septal deviations hampering the surgery were also corrected endoscopically. Depending on the group (A, B or C) in which the patient belonged to, appropriate middle turbinate interventions were done. Post operatively nasal cavity was packed with non-absorbable polyvinyl acetal nasal pack with drawstring (IVALON) for easy removal. Nasal pack was removed after 24 h of surgery.
Septal Turbinate Suturing
In septal turbinate suturing, the middle turbinates are sutured to the septum. A 3-0 Vicryl Plus (Braided coated Polyglactin 910 Violet, VP2437, Ethicon, India) suture on a 20 mm ½ circle round bodied needle is used (Fig. 1). Under endoscopic vision, from one side of the nasal cavity, the needle is pierced through the middle turbinate and the septal mucosa. It is then passed through the opposite side middle turbinate to its lateral aspect. The return stitch passes only through the septal mucosa anterior to the turbinate heads. At the level of the middle turbinate head the septum is bony, hence, in cases where septoplasty is not done, the return suture is passed anteriorly through the cartilaginous septum. This is obviated when a septal correction is done with removal of part of bony septum. The knot is tied to one side resulting in medialization of both the middle turbinates (Fig. 2).
Fig. 1.
The needle is passed through one side of the middle turbinate and the septum in a single movement
Fig. 2.
The Septal turbinate suture without septoplasty 1 and with septoplasty 2. MT middle turbinate; 3 Cartilaginous septum; 4 Bony septum
Partial Middle Turbinectomy
Under endoscopic vision using curved turbinectomy scissors a cut is made in the anterior lower third end of the middle turbinate corresponding to the ethmoidal infundibulum. A second cut is made joining the first from below upwards, thus freeing a small wedge of the anterior end of the middle turbinate. The same procedure is repeated on the opposite side (Fig. 3).
Fig. 3.
Anterior lower third of the middle turbinate is cut with turbinectomy scissors
Post operatively, the nasal pack was removed after 24 h of surgery. All the patients were given a course of antibiotics for 5 days following surgery. Saline nasal douching and topical corticosteroid nasal sprays were given for two weeks. Postoperative endoscopic toileting was done and the ease of access to the middle meatus was noted. The presence or absence of synechiae between the middle turbinate and lateral wall was also noted. Lund Kennedy endoscopic scoring was done for all patients at the end of 1st week, 4th week and 12th week. Quality of life (QOL) (SNOT-22) was done for all patients at the end of 4th week and 12th week following surgery.
The study variables among and between 3 groups were tested with Mann Whitney U Test. P value < 0.05 was considered statistically significant. IBM SPSS version 22 was used for statistical analysis.
Observation and Results
Of the 60 patients included in the study, 37 patients were males (61.7%), and 38.3% were females. All the three groups had majority of the cases in 41–50 years age group. Mean age at presentation was around 42.65 years. The mean age for groups A, B and C was 44.05 and 42.30 and 41.60 respectively.
Preoperatively the CT grading using Lund Mackey scoring was done. The mean scores of group A, B and C in the preoperative period were 12.90 ± 3.70, 12.15 ± 5.49 and 12.20 ± 4.79 respectively. Hence all groups had almost similar Lund Mackey scores preoperatively.
The mean Lund Kennedy score of Group A, Group B and Group C preoperatively was 10.00 ± 3.356, 9.90 ± 3.946 and 9.95 ± 3.316 respectively. All three groups had similar Lund Kennedy DNE scores preoperatively.
The mean SNOT-22 score of Group A, Group B and Group C was 37.15 ± 17.15, 35.85 ± 13.85 and 37.90 ± 18.10 respectively. There was no difference in the preoperative SNOT-22 scores between these three groups.
An inter group comparison of SNOT 22 scores between Group A (Septal turbinate suturing) and Group B (partial middle turbinectomy) was done and there was no statistically significant difference between group A and B in the postoperative periods at 4th and 12th week (Table 1).
Table 1.
Intergroup comparison between Group A and Group B
| Groups | Mean | SD | Mann–Whitney test | P Value | |
|---|---|---|---|---|---|
| Snot 22 | |||||
| Post OP 4 weeks | A | 26.10 | 16.567 | 164.500 | 0.336 |
| B | 21.20 | 9.699 | |||
| Post OP 12 weeks | A | 20.30 | 15.634 | 176.000 | 0.516 |
| B | 14.85 | 76.86 | |||
| Lund Kennedy | |||||
| Post OP 1 week | A | 3.90 | 1.971 | 148.500 | 0.157 |
| B | 2.95 | 1.791 | |||
| Post OP 4 weeks | A | 2.60 | 2.210 | 145.500 | 0.130 |
| B | 1.55 | 1.050 | |||
| Post OP 12 weeks | A | 1.45 | 1.191 | 160.000 | 0.255 |
| B | 1.00 | 0.725 | |||
Lund Kennedy Scores were also compared between Group A and Group B in the Postoperative period at 1st, 4th and 12th week (Table 1). There was no statistically significant difference in the scores among the two groups in the postoperative period.
SNOT 22 score between Group A and Group C was compared during postoperative 4th and 12th week (Table 2). There was no statistically significant difference in scores between group A and B in the postoperative periods.
Table 2.
Intergroup comparison between Groups A and C
| Groups | Mean | SD | Mann–Whitney test | P Value | |
|---|---|---|---|---|---|
| Snot 22 scoring | |||||
| Post OP 4 weeks | A | 26.10 | 16.567 | 161.000 | 0.291 |
| C | 29.15 | 15.229 | |||
| Post OP 12 weeks | A | 20.30 | 15.634 | 166.500 | 0.364 |
| C | 22.50 | 12.339 | |||
| Lund Kennedy score | |||||
| Post OP 1 week | A | 3.90 | 1.860 | 111.000 | 0.014 |
| C | 5.95 | 1.971 | |||
| Post OP 4 weeks | A | 2.60 | 2.210 | 123.500 | 0.036 |
| C | 3.85 | 2.084 | |||
| Post OP 12 weeks | A | 1.45 | 1.191 | 131.000 | 0.057 |
| C | 2.35 | 1.365 | |||
The mean Lund Kennedy scores in Group A decreased in 1st week and 4th week which further reduced in 12th week. Similarly, in Group C also there was a decrease in the mean Lund Kennedy scores in the 1st, 4th and 12th postoperative week. When the scores between the two Groups (A and C) was compared, there was a statistically significant improvement in scores in group A as compared to Group C in the 1st and 4th week (Table 2).
The mean SNOT-22 scores in Group B decreased in 4th week which further reduced in 12th week. Similarly, in Group C also there was a decrease in the mean SNOT-22 scores in the 4th and 12th postoperative week. When the scores between the two groups was compared, there was a statistically significant improvement in scores in Group B as compared to Group C (Table 3).
Table 3.
Intergroup comparison between Groups B and C
| Groups | Mean | SD | Mann–Whitney test | P Value | |
|---|---|---|---|---|---|
| Snot 22 scoring | |||||
| Post OP 4 weeks | B | 26.10 | 16.567 | 129.500 | 0.056 |
| C | 29.15 | 15.229 | |||
| Post OP 12 weeks | B | 20.30 | 7.686 | 119.500 | 0.029 |
| C | 22.50 | 12.339 | |||
| Lund Kennedy scoring | |||||
| Post OP 1 week | B | 2.95 | 1.791 | 78.000 | 0.001 |
| C | 5.95 | 1.860 | |||
| Post OP 4 weeks | B | 1.55 | 1.050 | 65.500 | 0.000 |
| C | 3.85 | 2.084 | |||
| Post OP 12 weeks | B | 1.00 | 0.725 | 100.000 | 0.005 |
| C | 2.35 | 1.365 | |||
The mean Lund Kennedy scores in Group B decreased in 1st week and 4th week which further reduced in 12th week. Similarly, in Group C also there was a decrease in the mean Lund Kennedy scores in the 1st, 4th and 12th postoperative week. When the scores between the two groups was compared, there was a statistically significant improvement in scores in Group B as compared to Group C (Table 3).
It was observed that post-operative assessment of the middle meatus by diagnostic nasal endoscopy was problematic in 15% of patients and difficult in 45% of patients in the non-interventional groups. The assessment of the middle meatus was relatively easier in Groups A and B (Table 4).
Table 4.
Ease of access to the middle meatus
| Access with ease | Access with difficulty | Cannot access | |
|---|---|---|---|
| Group A | 16 (80%) | 4 (20%) | 0 (0%) |
| Group B | 17 (85%) | 3 (15%) | 0 (0%) |
| Group C | 8 (40%) | 9 (45%) | 3 (15%) |
During the 12th week follow up, it was observed that none of the patients in Groups A and B had synechiae between the middle turbinate and lateral wall. 3 patients in Group C had evidence of synechiae which added to the difficulty in assessing the middle meatus (Table 5).
Table 5.
Synechia between the middle turbinate and lateral wall
| Present | Absent | |
|---|---|---|
| Group A | 0 (0%) | 20 (100%) |
| Group B | 0 (0%) | 20 (100%) |
| Group C | 3 (15%) | 17 (85%) |
Discussion
Chronic rhinosinusitis and Sinonasal polyposis are a part of the chronic inflammatory process. The nasal polyps are non-neoplastic lesions that represent the end stage of this inflammatory process in the sinonasal tract [6].
The estimated incidence of sinonasal polyps is 0.5–4% in the general population. The prevalence of SNP is between 1 and 4% in adults and 0.1% in children [6]. All patients above the age of 18 years were included in our study. The age of the patients ranged from 21 to 76 years with the mean age being 42.65. In our study out of a sample size of 60, 37 (61.7%) were males and 23 (38.3%) were females. Studies show that the occurrence of nasal polyps is more common in males than in females (2–4:1) [6]. Our study also had a similar sex predilection as reported in the literature.
The nasal polyps affect the quality of life of the patients by causing long-standing symptoms such as nasal obstruction, nasal discharge, smell disturbances, headache, facial pain, sneezing, postnasal drip. It also imposes a significant financial burden directly on outpatient appointments, investigations, medications, and hospitalizations. Indirectly as a result of missed workdays and decreased work productivity [6].
A meta-analysis by Soler et al. on the QOL outcomes in patients undergoing ESS which included 40 studies and 5547 patients, showed a significantly improved QOL in patients undergoing ESS [7]. Similarly all patients in our study showed a statistically significant improvement in SNOT 22 scores in the postoperative period as compared to the preoperative period. It was also observed that Group B (partial middle turbinectomy) showed a statistically significant improvement in SNOT 22 scores as compared to the non-interventional group. This study thus shows that there was an improvement in SNOT 22 scores in all the patients undergoing ESS for SNP. But the patients who underwent partial middle turbinectomy along with ESS had a better improvement in the overall scores at 12th postoperative week.
Middle turbinate lateralization has been cited as one of the most common factors leading to ESS failure, with its incidence ranging from 22 to 78%. A study by Musy and Kountakis on patients requiring revision Endoscopic sinus surgery over a period of two years showed that the most common anatomical finding associated with failure of primary surgery was lateralized middle turbinate (78%), followed by incomplete anterior ethmoidectomy (64%), scarred frontal recess (50%), incomplete posterior ethmoidectomy (41%), and middle meatal antrostomy stenosis (39%). The incidence of adhesion formation in postoperative period has been reported in about 27% of cases [8]. This obstructs sinuses and causes poor drug delivery of topical medications causing a recurrent disease and hence warranting revision surgery.
Various techniques for prevention of middle turbinate lateralization have been proposed, like placing stents and spacers between the middle turbinate and middle meatus, suturing of the middle turbinate and the septum, applying clips between the septum and turbinate, creating controlled synechiae between the septum and the turbinate and partial middle turbinectomy. In this study, we compare partial middle turbinectomy and suture conchopexy.
Each of these techniques have their own benefits and risks. Thorton advised suturing of the septum to the middle turbinate for stabilization [9]. LaMear et al. advised endoscopic partial middle turbinectomy for better postoperative outcomes [10]. Brescia et al. found an improvement in endoscopic score and statistically significant reduction of nasal airflow resistance after partial turbinectomy [11].
Various other studies have also found middle turbinate interventions beneficial. A prospective, randomized, blinded controlled study by Chen et al. found that the group with middle turbinate suturing had a significantly lower rate of MT lateralization and synechiae formation compared to the normal group [12]. A study by Hewitt and Orlandi showed that only 10.8% had adhesion of middle turbinate in the postoperative period following suturing of the middle turbinate and septum, the remaining 89.2% middle turbinates were normal [13].
When comparing the middle turbinate conchopexy with bolgerization, there was an improvement in the patency of the osteomeatal complex, mucosal healing and reduction in adhesion formation. A study by Hegazy et al. showed that both these procedures had no adverse effects on olfaction [14].
A study was done by Bofares on sixty patients who were, divided into four groups undergoing various procedures like: synechiae between MT and septum, partial middle turbinectomy, septal middle turbinate suturing and medialization of MT without fixation. The results of this study showed that there was a complete improvement in patients who underwent all the procedures except those who underwent medialization of MT without any fixation, where there was recurrence of sinustis. The author had attributed the cause for recurrence to either a synechiae between MT and lateral wall or to extreme lateralization of MT [15].
Our study assessed the ease with which the middle meatus could be accessed and found that the groups that underwent middle turbinate interventions showed a significant improvement in the access to the middle meatus when compared to the non-interventional group. 15% of patients in non-interventional group had developed synechiae and resultant lateralization of turbinates which caused difficulty in assessment of middle meatus at 12th week. There was no synechiae between the middle turbinate and the lateral wall in the interventional groups.
In our study Lund Kennedy endoscopic assessment showed that there was no statistically significant reduction of Lund Kennedy scores between both group A (septal turbinate suturing) and group B (partial middle turbinectomy). But a statistically significant difference was seen between the middle turbinate interventional and non-interventional group. Thus, a conclusion was derived that both the middle turbinate interventions were equivocal in preventing middle turbinate lateralization and synechiae formation.
There is no study in the literature comparing the efficacy of the middle turbinate conchopexy vs partial middle turbinectomy. Hence this study is the first and one of its kind, which compares the two techniques for creating and maintaining a wide middle meatus. From the results of our study, we can say that the middle turbinate intervention during the routine ESS for sinonasal polyps should be considered as one of the crucial steps that may significantly aid towards the improvement in the post-operative period.
One of the main concerns of procedures on the turbinate is the impairment of olfaction as middle turbinate medial edge also has olfactory function Even though our study did not specifically evaluate the olfaction, there was no specific complaints of hyposmia or anosmia among the study participants. A study conducted by Dutton and Hinton reported that MT suture medialization during ESS is an effective method for preventing lateralization of the MT and does not impair olfactory function [16].
In this study all the three groups benefitted from surgery for SNP. Group A and B showed better Lund Kennedy scores postoperatively compared to the non-interventional groups. The SNOT 22 scoring and QOL was better in the partial middle turbinectomy group. However, a larger sample size and longer follow-up period may be required to prove the efficacy of these techniques.
Conclusion
In this study it is observed that the middle turbinate intervention in the form of medialization suturing of middle turbinate and partial turbinectomy can be safely performed without any postoperative complications. However, further studies in both these interventional groups (medialization suturing of middle turbinate and partial middle turbinectomy) are required for a longer period, to assess the benefits of the procedure and the recurrence of SNP.
Acknowledgements
I would like to acknowledge our Head of the Dept. Dr.L.Somu, faculties and collegues for their valuable help in data collection and editing.
Declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Footnotes
Publisher's Note
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