Middle Turbinate Lateralization Research Articles

Anatomical findings in patients with chronic rhinosinusitis without nasal polyps requiring revision surgery

ObjectivesFor the treatment of chronic rhinosinusitis functional endoscopic sinus surgery is a well-established therapy with high initial success rates. However, a significant proportion of patients have persistent disease requiring revision surgery. To date, studies including data of large patient collectives are missing. In this study, we aimed to identify anatomic factors increasing the need for revision surgery in a large patient collective with chronic rhinosinusitis without nasal polyps. MethodsData were collected retrospectively on patients with recurrent or persistent chronic rhinosinusitis without nasal polyps requiring revision surgery. The patients’ symptomatology, endoscopic and radiographic findings were analyzed. Preoperatively, patients were evaluated with endoscopic examination of the nose and paranasal sinuses. In all individuals computed tomography of the sinuses was performed. Images were evaluated according to the Lund-Mackay system. Information was also collected intraoperatively. Results253 patients were included. The most common anatomic factor was incomplete anterior ethmoidectomy (51%), followed by residual uncinated process (37%), middle turbinate lateralization (25%), incomplete posterior ethmoidectomy (20%), frontal recess scarring (19%), and middle meatal stenosis (9%). Other factors such as persistent sphenoid pathology was less frequent. ConclusionIatrogenic causes with inadequate resection of obstructing structures seem to be a principal risk factor for recurrent chronic rhinosinusitis and the need for revision sinus surgery. Meticulous attention in the area of the ostiomeatal complex during surgery with ventilation of obstructed anatomy as well as avoidance of scarring and turbinate destabilization may reduce the failure rate after primary endoscopic sinus surgery. Level of evidence2b.

Intact Bulla Versus Trans-Axillary: Which is a Better Approach to Frontal Sinus?

Frontal sinus is one of the most difficult sinuses to approach endoscopically because of its anatomical location. Challenges and difference in opinions still exist in terms of its surgical management. Endoscopic approach to frontal sinus commonly involves either trans-axillary or intact bulla technique. Trans-axillary technique gives a direct access to the frontal sinus even with a 0° endoscope whereas Intact bulla technique warrants the use of 70° scope. Despite both the techniques now existing for quite some time; literature is still controversial regarding the superiority of one technique over the other. A randomised prospective study of 40 patients of frontal sinusitis. Patients were randomly allocated into two groups. In approaching frontal sinus, groupA patients underwent trans-axillary technique and group B patients underwent intact bulla technique. Both the groups were statistically compared in terms of time taken for surgery, post operative results and improvement in symptom score. The pre-operative endoscopic Lund -Kennedy score in group A was 7.1 ± 1.57 while in group B was 6.95 ± 1.1. The mean post -operative endoscopic Lund Kennedy score in group A was 1.25 ± 0.93. and in group B was 1.05 ± 0.89. The mean pre& SNOT-22 score in group A was 79.85 ± 19.1 and in group B was 80.55 ± 16.94. The mean postoperative SNOT-22 Score in Group A was 4.450 ± 2.136 and group B was 2.579 ± 1. 714.The average time taken in group A to reach frontal sinus was 21.1 ± 5.44min while in group B it was15.9 ± 3.6min. At 12 weeks follow up recurrence was seen in 4/20 cases in group A and 3/20 Cases in group B. Ostial Stenosis was seen in 3/20 cases in group A and 2/20 cases in group B. Nasal adhesions were seen in 7/20 cases in group A and 1/20 cases in group B. Middle turbinate lateralization was seen in 8/20 cases in group A and 1/19 cases in group B. Lamina Papyracea injury was seen in 1 case in group B but in 3 cases of group A. Both the techniques were highly efficacious in improving post-operative endoscopic as well as symptom scores. However, some post operative complications like middle turbinate lateralization were more with trans-axillary technique as compared to intact bulla technique.

Efficacy of Steroid-Impregnated Spacers After Endoscopic Sinus Surgery in Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis.

The aim of this study was to compare the effect of steroid-impregnated spacers to that of conventional management after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). Six databases were searched from inception until November 2022. Sixteen studies were found that compared the improvement of chronic sinusitis-related symptoms and postoperative outcomes between a steroid-impregnated spacer group and a control group (non-steroid-impregnated spacers). The Cochrane risk of bias tool (for randomized controlled studies) and the Newcastle-Ottawa Scale (for non-randomized controlled studies) were used to assess the quality of the works included. Regarding the endoscopic findings, the degree of mucosal edema, ethmoid inflammation, crust formation at 2-3 months postoperatively, nasal discharge, polyposis, and scarring/synechia were significantly lower in the steroid-impregnated spacer group. The steroid-impregnated spacer group also showed significantly lower Lund-Kennedy scores and perioperative sinus endoscopy scores than the control group at 2-3 weeks postoperatively. Furthermore, the steroid-impregnated spacer group had lower rates of adhesions, middle turbinate lateralization, polypoid changes, the need for oral steroid use, the need for postoperative therapeutic interventions, and lysis of adhesions than controls. However, no significant between-group differences were found in short-term (2-3 weeks postoperatively) endoscopic findings regarding nasal discharge, postoperative crusting, polyposis, or scarring/synechia. Steroid-impregnated nasal packing reduced the rates of postoperative intervention and recurrent polyposis and inflammation in CRS patients undergoing ESS.

Outcomes of middle turbinate-septal adhesion technique and trans-septal middle turbinate suture technique to prevent middle turbinate lateralization: a comparative study

Background Middle turbinate lateralization (MTL) is the most common undesirable sequela after functional endoscopic sinus surgery (FESS), which can result in recurrent sinusitis. Objectives To examine the efficacy and outcomes of different techniques to prevent failure of the primary surgery. Patients and methods Eighty patients who presented with chronic rhinosinusitis listed for FESS were enrolled in this study. Patients were divided randomly into two groups, with 40 patients each. In group A, middle turbinate (MT) was stabilized by adhesion technique, and in group B, MT was stabilized via suture technique. A comparison of the effectiveness and the outcomes of both techniques was done by assessing the MT position and synechiae formation, which is considered a primary outcome. Secondary and tertiary outcomes were assessed through Lund–Kennedy Score and Lund–Mackay, and Sino-nasal Outcome Test-8 and Sniffin Sticks identification test scores, respectively. Results Although a higher incidence of MTL and synechiae was detected in the adhesion group after 1, 3, and 6 months of follow-up, there was no significant difference between both groups, with P values of 0.74, 0.11, and 0.089, respectively. We found at the end of the sixth month postoperatively, a noticeable improvement in Lund–Kennedy Score, Lund and Mackay Score, Sino-nasal Outcome Test-8, and Sniffin Sticks identification test scores in both groups, with P values of 0.0004/0.0002, 0.001, 0.000, and 0.0002/0.0001, respectively, which are highly statistically significant differences, but there was no significant difference among both groups, with a P value of 0.24. Conclusion The primary goal must be considered to be prevention of MTL, and the medialization techniques should not be carried out routinely in FESS.

Management of the middle turbinate during and after sinus surgery.

Treatment of the middle turbinate (MT) during and after endoscopic sinus surgery (ESS) has been controversial. Historically, there has been concern that resection of the MT may result in smell loss and frontal sinus stenosis. However, these concerns must be balanced by knowledge that a residual diseased MT may result in surgical failure. This review discusses the current evidence on treatment of the MT during and after ESS. Several review articles have shown the safety of performing MT resection. Studies have not shown increase rates of frontal sinus stenosis, olfactory loss, or empty nose syndrome. However, the benefit of MT resection is highly debated. There have also been many recent advances and technological developments to assist in management of the postoperative MT. The literature supports the safety of performing MT resection, however, the benefit of resection over preservation is controversial. New technologies and techniques exist that may aid in preventing postoperative MT lateralization.

Evaluation of Computed Tomography Findings in Revision Endoscopic Sinus Surgery

Objective: To investigate computerized tomography (CT) data of patients who needed revision surgery for chronic rhinosinusitis. Material and Methods: 83 patients who underwent revision endoscopic sinus surgery by the senior author due to recurrent and/or persistent chronic rhinosinusitis were included in this study. The following data were obtained from preoperative CT scans and recorded for each side of every patient: recurrent polyposis, incomplete uncinectomy, retained agger nasi cell, lateralization of middle turbinate, recirculation phenomenon, maxillary antrostomy stenosis, incomplete anterior and posterior ethmoidectomy, scarring at the frontal recess, sphenoid ostium stenosis, or novel onset sphenoid disease. Results: Based on our findings, septal deviation caused inadequate posterior ethmoidectomy, while incomplete uncinectomy increased the risk of frontal sinus disease. Conclusions: We suggest that septum deviation may cause insufficient visualization, while incomplete uncinectomy may prevent adequate intervention to the frontal sinus and these subsequently play a role in ESS failure.

Preventive Measures of Middle Turbinate Lateralization After Endoscopic Sinus Surgery: An Updated Review.

Introduction: The middle turbinate (MT) is the most important anatomical structure inside the nasal cavity and a landmark in the identification of skull base, ethmoid cells, and lamina papyracea. Postoperatively, lateralizationof the MT can cause synechia and obstruction of the middle meatus and the maxillary, ethmoid, or frontal sinuses.Objective: To review the current literature about the outcome of different techniques used intraoperatively to prevent lateralization of MT after functional endoscopic sinus surgery (FESS).Materials and methods: This retrospective narrative literature review provides a summary of current and past research publications about different techniques used intraoperatively to prevent MT lateralization after FESS.Results: Many methods have been described to prevent the lateralization of MT and synechiae formation. These methods include controlled synechiae, suture lateralization, metal clips, partial resection of MT, middle meatus implants, and steroid-eluting implants and stents.Conclusion: The ideal FESS should include preservation of the MT, reducing its lateralization, and preventing synechia formation.Different techniques have been discovered in an attempt to prevent this complication.

Comparison between the endoscopic scores of bolgerization versus partial resection of the middle turbinate for management of the postoperative lateralization in the early follow-up period after endoscopic frontal sinusotomy: A randomized controlled study

BackgroundFrontal sinusotomy is a challenging procedure that needs meticulous handling due to its unique anatomical position. Postoperative middle turbinate lateralization is critical comorbidity for the success rate, and many techniques are adopted to prevent it. The study aimed to compare the effect of middle turbinate bolgerization and partial resection on the postoperative endoscopic scores and assess their impact on the middle meatus and the frontal recess outcome. Patient and methodsThis prospective study was conducted on forty-one patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis. Nasal cavities were randomized so that partial middle turbinate resection technique was done alternately with bolgerization approach in every patient. Each participant acted as their control. Both sides were compared using Lund Kennedy Endoscopic Score (LKES) and Perioperative Sinus Endoscopy Score (POSE) at the baseline, 1st, 3rd, and 12th-month intervals postoperatively. Also, middle turbinate status was assessed at the end of the 12th-month interval using POSE score. ResultsThe total frontal sinus patency rate was 82.9% (63/76 operated sinus). Baseline scores, LKES (3.79 ± 0.777 vs 4.05 ± 0.769, p = 0.142, for the side of resection and the side for bolgerization respectively) and POSE (1.79 ± 0.413 vs 1.82 ± 0.393, p = 0.777, for the side of resection and the side for bolgerization respectively). Regarding LKES, the differences between both operated sides were fluctuating with p values: 0.001*, 0.171, and 0.044* for the 1st, 3rd, and 12th months follow-up intervals, respectively. Regarding the POSE score of the frontal sinus, the difference between both groups was steadily increasing with p values: 0.318, 0.119, and 0.017* for the 1st, 3rd, and 12th months follow-up intervals. The middle turbinate's POSE score at the 12th month was significantly higher in the side allocated for bolgerization (p-value = 0.008*). ConclusionPartial middle turbinate resection showed favorable endoscopic outcomes than bolgerization at the 12th month follow up period in patients undergoing primary ESS for chronic frontal sinusitis.

Comparison of Bioabsorbable Steroid-Eluting Sinus Stents Versus Nasopore After Endoscopic Sinus Surgery: A Multicenter, Randomized, Controlled, Single-Blinded Clinical Trial.

The aim of this study was to compare the efficacy of bioabsorbable steroid-eluting sinus stents versus absorbable Nasopore packs after endoscopic sinus surgery (ESS) for the treatment of chronic rhinosinusitis (CRS). One hundred eighty-one patients with CRS who underwent ESS were randomly assigned to receive a steroid-eluting sinus stent in one ethmoid sinus cavity, whereas the contralateral control side received a Nasopore pack. Endoscopic evaluations were performed 14, 30, and 90 days after the ESS. Postoperative intervention, polyp formation, adhesions, and middle turbinate (MT) position were assessed as efficacy outcomes. The stents were successfully deployed in all 181 sinuses. Thirty days after the ESS, the stents significantly reduced the need for surgical intervention compared to the Nasopore (P < .0001). The percentage of cases with polyp formation was significantly lower on the stent sides compared with the Nasopore sides (P < .0001) at 14, 30, and 90 days after ESS. The percentage of severe adhesion was significantly lower on the stents sides than on the Nasopore sides at postoperative day 90 (P = .0003), whereas they were not significantly lower at postoperative days 14 and 30. There were no significant differences between the stent sides and the Nasopore sides regarding the frequency of MT lateralization at all end points. No device-related adverse events occurred. Our study demonstrated significant improvement in the early postoperative outcomes by reducing the need for postoperative surgical intervention and polyp formation using steroid-eluting stents when compared with absorbable Nasopore packs. The steroid-eluting sinus stents and the Nasopore packs were each effective in preserving the ethmoid sinus patency and in preventing MT lateralization. A further prospective cohort study with long-term postoperative outcomes is warranted.

Doyle silicone splint insertion: endoscopy-assisted versus nasal speculum assisted

IntroductionSeptoplasty and endoscopic sinus surgery are very often concurrently performed operations in otolaryngology practice. The most common complication of endoscopic sinus surgery is lateralization of the middle turbinate. In our practice intranasal stenting is done routinely with Doyle silicone splints. ObjectiveRetrospectively, we aimed to review the postoperative period and to document efficacy of endoscopy-assisted Doyle silicone splint application on prevention of middle turbinate lateralization. MethodsPatients who had failed medical therapy and who underwent elective primary endoscopic sinus surgery for chronic rhinosinusitis with septal deviation requiring septoplasty were included to the study. Doyle silicone splints were inserted to all patients at the end of the operation with nasal speculum or with endoscopic assistance. Groups were compared for position of the middle turbinate at the end of the postoperative first month regarding lateralization and for pain score recorded on the second postoperative day. ResultsIn the Doyle silicone splints applied with nasal speculum group, there were 46 patients with a total of 80 operated sides. In the endoscopy assisted group, there were 54 patients with a total of 88 operated sides. At the 1 month follow-up, the mean of middle turbinate position scores was 1.62 in the speculum-assisted group and 1.80 in the endoscopy-assisted group, the difference between two groups was found to be statistically significant. Mean of postoperative second day pain scores were worse in patients with the Doyle silicone splints applied with endoscopic assistance. This difference was found statistically significant. ConclusionIn our study, after concomitant endoscopic sinus surgery and septoplasty, less middle turbinate lateralization was observed when the Doyle silicone splints were inserted with endoscopic guidance. The surgical techniques or methods of sinus packing as well as nasal packing may have an impact on middle turbinate lateralization after concurrent septoplasty and endoscopic sinus surgery.

Efficacy and safety of steroid-impregnated implants following sinus surgery: A meta-analysis.

The purpose of this meta-analysis was to discuss the efficacy and safety of bioabsorbable steroid-impregnated implants following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) patients. PubMed, Cochrane, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were comprehensively searched for studies comparing the experimental group (bioabsorbable steroid-impregnated implants) with the control group (bioabsorbable nonsteroid-impregnated implants). Lund-Kennedy scores, Perioperative Sinus Endoscopy (POSE) scores, polyp change, significant adhesion, middle turbinate lateralization, and adverse events were extracted from the final eligible studies. RevMan 5.3 software was used to analyze the data. Eight randomized controlled trials were included in our analysis. The experimental group showed no significant differences from the control group in Lund-Kennedy scores (weighted mean difference (WMD) -0.40; 95% confidence interval [confidence interval (CI)] -1.05 to -0.62; P = 0.23). The experimental group had lower POSE scores compared with the control group, and there was a significant difference (WMD -1.88; 95% CI -2.32 to -1.43, P < 0.00001). The pooled results also demonstrated significant differences in polyp change, significant adhesion, and middle turbinate lateralization between the two groups. In addition, there was no significant difference with respect to adverse events between the two groups (odds ratio (OR) 0.38; 95% CI: 0.07 to 2.03; P = 0.26). Bioabsorbable steroid-impregnated implants following ESS are effective in improving the endoscopic appearance of the healing process, and the safety profile appears to be favorable for the treatment of CRS patients. 1A Laryngoscope, 2019.

Comparison of steroid-releasing stents vs nonabsorbable packing as middle meatal spacers.

A randomized controlled trial was held to compare nonabsorbable packs to steroid-eluting absorbable stents as middle meatal spacers after endoscopic sinus surgery in patients with chronic rhinosinusitis (CRS). CRS patients were randomly assigned to receive either nonabsorbable Merocel packs wrapped in non-latex glove material (packing type A) or Propel steroid eluting stents (packing type B). Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores were collected preoperatively and postoperatively during the initial 4 debridements up to 3 months. Recording of the nasal endoscopy was also collected during all postoperative visits. In addition, Lund-Kennedy scores and middle turbinate lateralization scores, using a new visual analogue scale, were compared between the 2 types of packing. Forty CRS patients were prospectively enrolled in this institutional review board (IRB)-approved study. Patients with packing type A had significantly lower middle turbinate lateralization scores at their first (∼10 days) postoperative visit (p = 0.02 and p = 0.04, for left and right sides, respectively). This difference disappeared by later postoperative visits (from 20 days to 3 months). Overall, patients receiving packing type A had significant lower SNOT-22 scores at 20 days postsurgery (p = 0.05). This difference also disappeared at 1 and 3 months postoperation. There were no statistically significant differences in Lund-Kennedy scores. In this study, nonabsorbable packing materials showed significant superior middle meatal spacing capacities as evidenced by greater middle turbinate medialization capability at the first postoperative visit. Additionally, patients with this type of packing saw improvements in their SNOT-22 scores at the 20-day postoperative visit. This study showed that there was no significant improvement in postoperative outcomes with drug-eluting stents when compared to nonabsorbable packing.

Impact of Suture Conchopexy on Olfaction and the Risk of Middle Turbinate Lateralization.

Introduction: Middle turbinate (MT) lateralization is one of the common causes of endoscopic sinus surgery (ESS) failure and often necessitate revision surgery. To avoid this sequala, surgeons have attempted several methods to keep the MT medialized. One such method is conchopexy. However, the impact of this procedure on olfaction remains unclear.Method: A retrospective cohort study was conducted to compare the subjective olfaction outcome of ESS in patients for whom conchopexy was performed and in controls where a spacer was applied in the middle meatus. Also, the risk of lateralization in both techniques was compared. In addition, other factors related to the outcome of olfaction, such as age, gender, type of chronic rhinosinusitis (CRS), and partial resection of the MT, were assessed.Results: Out of 299 patients with CRS who underwent ESS, 134 met our inclusion criteria. In total, 62.7% were male and 37.3% were female, and their mean age was 37.4 years. Sixty-one patients (cases) underwent conchopexy, and 73 patients (controls) underwent insertion of a middle meatus spacer. None of the subjects in both groups developed anosmia or hyposmia as a complication. The improvement of olfaction was almost equal in both groups (for anosmia: 92.9% in cases vs. 87.5% in control; for hyposmia 87.1% in cases vs. 89.7% in control). In patients with anosmia, the improvement of olfaction was lower when the MT was partially resected (71.4% vs. 95.7%); whereas, in patients with hyposmia, the improvement was not significantly different (87% vs. 93.8% when the MT was partially resected). The improvement of olfaction was higher in patients with allergic fungal sinusitis (AFS) and CRS with nasal polyps (CRSwNP) than in those with CRS without nasal polyps (CRSsNP). The MT lateralization was almost equal in both groups (9.0% in cases vs. 9.6% in controls).Conclusion: Conchopexy does not affect olfaction subjectively. The improvement of olfaction is related more to the underlying disease, i.e., less improvement occurs in cases of CRSsNP. The risk of lateralization is equal with either conchopexy or middle meatus spacer.

Effect of steroid-releasing sinus implants after endoscopic sinus surgery (ESS) on postoperative outcomes: A meta-analytical study

Aimsa meta-analysis to evaluate the steroid-releasing sinus implants in chronic rhinosinusitis (CRS) patients after functional endoscopic sinus surgery (FESS) in order to assess its efficacy.Settings and DesignMeta analysis.Methods and MaterialThe 4 trials enrolled a total of 539 patients utilizing an intrapatient control design. Postoperative day 30 videos were obtained for each patient, randomly ordered for grading of efficacy endpoints. The need for postoperative interventions, formation of polyposis, and adhesions were assessed. Results from the 4 studies were then pooled.Statistical analysis usedComprehensive Meta-Analysis© version 2 (BiostatTM, NJ, USA).ResultsImplants were successfully placed. According to the grading done by the panel, drug-releasing implants reduced significant adhesions by 2.5% (P=0.971), middle turbinate lateralization occurrence was 2.5% (P=0.954), polyp formation was 2% (P=0.830), the need for oral steroid intervention was 22% (P=0.173), significantly less need for postoperative therapeutic intervention 33% (P=0.305), or Surgical Lysis of Adhesions (LOA) intervention 14% (P=0.951), compared to controls.ConclusionsSteroid-releasing implants improve surgical outcomes by reducing frank polyp formation, sinus adhesions, and middle turbinate lateralization. Steroid-releasing implants reduce the need for surgical intervention, and the need for oral steroid treatment.

Turbinate-septal suture for middle turbinate medialization during endoscopic sinus surgery

Background Lateralization of middle turbinate (MT) and synechia formation are common complications after endoscopic sinus surgery (ESS). These complications can be prevented with one of MT medialization techniques. Aim The aim of this study was to evaluate the effectiveness of MT-septal suturing technique in prevention of lateralization of MT and synechia formation after ESS. Patients and methods A total of 25 patients were selected for this prospective cohort study in the period between January 2017 and January 2018 at the Otorhinolaryngology Department, Tanta University Hospital, complaining of chronic rhinosinusitis refractory to medical treatment. The age of the patients ranged from 16 to 60 years. We selected patients who did not have a history of previous ESS, nasal tumors, or bleeding disorders. A total of 25 patients of the study had undergone MT medialization (suturing technique) after ESS. All the patients were assessed by endoscopic nasal examination (preoperative, 2 weeks, and 3 months postoperatively) and sinonasal outcome test (SNOT-22) questionnaire (preoperatively and 3 months postoperative). Results Two-week postoperative endoscopic nasal examination of 25 patients showed that there was mild adhesion and synechia to lateral nasal wall in two patients in one side (8%) owing to separated sutures. Synechia was divided in outpatient clinic. No synechia was detected on 3-month postoperative endoscopic examination. Conclusion Lateralization MT and synechia formation after ESS complications can be prevented with one of MT medialization techniques. The MT suturing technique is simple, reliable, and effective in prevention of lateralization of MT and synechia formation after ESS.

A Prospective Study on the Safety and Effectiveness of a Composite Sinus Stent for Use After Endoscopic Sinus Surgery.

The composite sinus stent was developed to support the nasal walls, stabilize the middle turbinate, and prevent adhesions following endoscopic sinus surgery (ESS). This study sought to assess its safety and effectiveness. A prospective clinical trial was conducted in a single medical center in 2016-2018. The study included 30 patients (64% males) with a mean age of 41.9 years, who were scheduled for bilateral ESS, were randomized to undergo composite sinus stent implantation for 14 to 28 days or middle meatus placement of a Telfa tampon for 2 to 3 days. Telfa is a nonadherent absorbent dressing that has been compared favorably with other packs for use following ESS. Both groups received the same postoperative treatment. Outcomes were evaluated endoscopically by the principal investigator and also by an independent investigator blinded to the intervention the patient had and by self-report questionnaires at 3 and 12 weeks postoperatively. The stent was successfully implanted and removed in all 29 treated sinuses, without complications. None of the stents showed granulation tissue or crusting. Compared to the tampon group, the stent group had significantly less inflammation (mean visual analog scale scores 0.2 vs 4.2 at 12 weeks, P = .01). The probability of having adhesion was 9.3 times greater in the control group compared to the study group ( P = .026), and middle turbinate lateralization rate at 12 weeks was 3.8% versus 44% in the study group and the control group, respectively, at 12 weeks ( P = .006). Patients who underwent stent implantation experienced higher symptomatic improvement (Sino-Nasal Outcome Test 22 of -37.13 vs -28.07, P = .01, in study and control groups, respectively). During stent implantation (2-4 weeks), patients did not suffer from any discomfort. The composite sinus stent is safer and more effective than the Telfa tampon in maintaining sinus cavity patency and promoting healing following ESS.

Silastic "Spring" Spacers for Use Following Endoscopic Sinus Surgery.

The prevention of middle turbinate lateralization, and middle meatal synechiae formation, is the key to maintain a patent ostiomeatal complex following endoscopic sino-nasal surgery (ESS). Different techniques have been described to prevent this undesirable outcome, however, most of them are invasive, expensive, uncomfortable and/or obstructive. We present our technique to modified silastic sheets to circumvent these problems and improve ventilation and drainage of sinuses after surgery. The aim of this paper is to present how this silastic sheeting can be easily customized to the shape of the ethmoid cavity after ESS, allowing for ventilation of the aerated sinonasal cavities and at the same time preventing problematic synechiae/scar formation. A practical and easy technique to customize silastic stents following ESS is presented. Silastic sheets could be easily customized of the ethmoid cavity after ESS providing an excellent alternative to reduce middle turbinate lateralization and synechiae formation.

The axillary flap is a safer but tedious technique for Agger nasi cell removal compared to punch out procedures

Objective:This study prospectively assessed the axillary flap approach versus punch-out procedure for agger nasi cell (ANC) removal.This is akey for successful frontal sinus surgery and its implication on the patency of the frontal ostium and middle turbinate lateralization(MTL). Subjects and Methods: The study subjects consisted of 50 patients of whom 30 patients were males (80 frontal sinuses; 30 patients with bilateral disease and 20 patients with unilateral disease) with proven chronic frontal sinusitis, with pneumatized ANC according to CT findings.All patients undergone Endoscopic Sinus Surgery (ESS) with dissection of frontal recess. Group I included 40 sides that undergone removal of ANC using the axillary flap procedure (procedure 1), Group II included 40 sides that undergone removal of ANC using the punch out procedure (procedure 2). Adelaide chronic rhinosinusitis (CRS) symptom scoring questionnaires was used to all patients during their last follow-up visit 3 months after surgery. Results: ANC were the most common variation and were observed in all the patients (20 patients unilaterally and 30 patients bilaterally). MTL following ANC removal has been found in 7.5% ofGroup I and 25% in Group II patients. Association between Adelaide symptoms severity score of postoperative symptoms and MTL was significant for nasal obstruction and rhinorrhea in both procedures (1 and 2). Non visualization of the frontal ostium following ANC removal has been found in 7.5% of Group I and 15% in Group II.Comparison between both procedures on MTL and non-visualization shows that the number of patients with MTL-positive using procedure 1 was significantly less than procedure 2 while there was a non-significant difference between procedure 1 and 2 regarding non-visualization. Conclusions: The axillary flap technique is a safer procedure for resection of the ANC with perfect healing and less incidence of intraoperative and postoperative complications.However, it is a relatively difficult procedure and very time consuming while punch out procedure is a relatively easy, less time consuming procedure.

Clinical effects of submucosal middle turbinectomy for eosinophilic chronic rhinosinusitis

ObjectiveThe preservation or resection of the middle turbinate (MT) during endoscopic sinus surgery (ESS) currently remains a matter of debate. The present study aimed to investigate the effects of submucosal middle turbinectomy (SMT) in ESS for eosinophilic chronic rhinosinusitis (ECRS). MethodsThe study included 38 ECRS patients (63 sides) who had undergone full-house ESS with SMT and 20 ECRS patients (40 sides) without SMT as a control group. Post-operative middle turbinate lateralization (MTL), synechia formation, and the patency grade of the olfactory cleft (OC) were assessed as the primary outcomes 3 months after surgery. CT scans and the T&T test were performed on the SMT group 3 months after surgery and assessed as secondary outcomes. ResultsMTL and synechia formation rates were slightly higher in the control group than in the SMT group (20% vs. 7.9%, p=0.072, 17.5% vs. 9.5%, p=0.235), although neither reached statistically significance. The mean patency score of OC was significantly better in the SMT group than in the control group (0.5±0.6 vs. 1.3±0.7, <0.001). CT findings and T&T test scores showed good improvements after SMT combined with ESS. No major adverse events occurred due to SMT. ConclusionWe demonstrated the potential advantages of SMT for ECRS patients. This method may avoid physiological functional loss through its preservation of the mucosa and structure of the MT.

The status of the middle turbinate and the risk of sinusitis after endoscopic transnasal sphenoidotomy.

The objectives of this study are to evaluate the occurrence of postoperative middle turbinate lateralization and the relationship between this lateralization and the risk of iatrogenic sinusitis after endoscopic transnasal sphenoidotomy procedure. Patients who undergone endoscopic transnasal sphenoidotomy and came under the surveillance of our otorhinolaryngology department between the January of 2010 and the December of 2015 were retrospectively scanned. Among them, the patients who were evaluated with paranasal sinus computed tomography (CT) postoperatively were included in the study. The amount of middle turbinate lateralization in each patient was evaluated by comparing their routine preoperative CT image with the postoperative CT image. The air-fluid levels or soft tissue opacifications in the sinuses or obstruction of the ostiomeatal complex were accepted as the evidence of sinusitis on the images. The patients were asked questions regarding their symptoms of sinusitis on a phone interview for the statistical evaluation of their preoperative and postoperative Visual Analog Scale scores of complaints of sinusitis. The difference between preoperative and postoperative measurements was found to be statistically significant (p<0.001, 95% CI). The middle turbinate position was lateralized in 31 patients (81.6%), medialized in four patients (10.5%), and remained unchanged in three patients (7.9%). Overall, the sinus opacification and mucosal thickening rates did not change significantly which suggested the operation did not pose patients at increased risk of sinusitis. Mean VAS scores of complaints of sinusitis did not change significantly except for sensation of facial pressure, which showed a minor but statistically significant decrease (p<0.001). This study revealed the lateralization of the middle turbinate after transnasal sphenoidotomy. However, it seemed that this lateralization did not create a predisposing factor for the development of acute and chronic sinusitis.