Middle Turbinate Resection Research Articles

Middle turbinate handling during ESS. Our experience

PurposeThe treatment of middle turbinate (MT) during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) remains a controversial issue. Several authors recommended preservation of MT to avoid complications, but MT resection is sometimes necessary. In the last years, our group has applied an original surgical technique to preserve MT, stabilize its head and ensure patency of the ostiomeatal complex (OMC) in ESS. We herein described this approach to the MT and reported its preliminary results in terms of post-operative endoscopic features and complications. MethodsThe study retrospectively considered 34 consecutive adult patients suffering from CRS and treated with primary or revision ESS. Medialization of the MT and its stabilization to achieve post-operative patency of the OMC was obtained by means of: (i) creation of a surgically controlled synechia between the MT head and nasal septum; (ii) positioning of a silicone plate in the OMC. The silicone splints kept the MT head in an obliged position to contact the septum. ResultsAt 12-month follow-up control, we found: (i) stabilized MT medialization in all treated cases, (ii) only one case of lateral synechia without recurrent CRS, and (iii) a polypoid recurrence rate of 13%. ConclusionsThe MT handling technique during ESS herein preliminarily described seems to be an effective approach to medialize and stabilize the MT. This technique could be particularly appropriate for unstable MT after removing massive inflammatory lesions of the mucosa.

Middle turbinate resection is unlikely to cause empty nose syndrome in first year postoperatively

PurposeEmpty nose syndrome (ENS) is characterized by nasal dryness, crusting, and paradoxical nasal obstruction most commonly after inferior turbinate resection. ENS has also been reported to occur after middle turbinate resection (MTR), and concern for causing ENS is a possible reason surgeons preserve the MT during endoscopic sinus surgery (ESS). The objective was to determine whether MTR during ESS led to ENS. Materials and methodsThis was a prospective case series of 95 consecutive patients that underwent bilateral subtotal MTR during ESS with either Draf IIB or Draf III frontal sinusotomies, for chronic rhinosinusitis with or without nasal polyps, and frontal sinus inverted papillomas. Demographic data and postoperative Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores were obtained. Nasal crusting was also documented on last postoperative nasal endoscopy. ResultsPathologies included chronic rhinosinusitis with nasal polyps (69), without nasal polyps (12), and inverted papillomas (14). Fifty-six patients underwent subtotal MTRs during ESS with Draf IIB, and 39 with Draf III. Mean follow-up was 19.4 months (range 12–49). Mean postoperative ENS6Q score was 2.1. Only 2.1% had ENS6Q scores ≥ 11, and 6.3% had nasal crusting at last follow-up. None of the patients with ENS6Q scores ≥ 11 had nasal crusting at last follow-up. There were no significant differences in outcomes between ages, genders, surgery types, or pathologies. ConclusionsPatients who underwent bilateral subtotal MTR during ESS were unlikely to develop ENS by at least 1 year postoperatively, based on patients rarely experiencing ENS6Q scores ≥ 11 or persistent nasal crusting.

Chronic rhinosinusitis with nasal polyps: predictive factors for recurrence and revision surgery

<p class="abstract"><strong>Background:</strong> Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory condition which may have a significant impact on quality of life. Endoscopic sinus surgery (ESS) is indicated for patients refractory to maximal medical treatment and presents high recurrence and revision surgery rates. Aim of the study was to evaluate ESS outcome in CRSwNP management and to assess independent predictive factors for recurrence and revision surgery.</p><p class="abstract"><strong>Methods:</strong> Retrospective medical chart review of patients who underwent ESS for recalcitrant CRSwNP, from January 2013 to December 2017, with a minimum follow-up time of 12 months. </p><p class="abstract"><strong>Results:</strong> This study enrolled 132 patients, 62.1% of whom were males, with a mean age of 43.4±11.5 years. Asthma was the most common comorbidity (39.4%, n=52) and aspirin exacerbated respiratory disease (AERD) was present in 9.8% (n=12) of the study population. We found a recurrence rate of 34.1% (n=45) and 9% (n=12) of patients required revision surgery. Multivariate analysis identified as independent variables of recurrence (95% CI): a history of asthma (OR=8.81, CI 3.87-20.03; p<0.001) and a severe Lund-Mackay score (17-24) (OR=5.85, CI 2.73-12.51; p=0.001). Revision surgery was related to a severe endoscopic Lund-Kennedy score at presentation (OR=4.05, CI 1.91-8.01, p=0.001).</p><p class="abstract"><strong>Conclusions:</strong> CRSwNP presents a high tendency to recur after ESS. Asthma, severe sinus opacification and severe endoscopic score are poor prognostic factors that hallmark a more aggressive disease. A more extensive surgical procedure and/or middle turbinate resection with a rigorous postoperative compliance should be considered to improve long term results.</p>

Predictors of long-term success and failure in primary and revision endoscopic dacryocystorhinostomy.

Although endoscopic dacryocystorhinostomy (endo-DCR) is a common treatment of nasolacrimal duct obstruction, little is known about the determinants of surgical success and failure. The purpose of this study was to identify patient- and technique-specific factors that may influence surgical outcomes of primary and revision endo-DCR. A retrospective review was conducted of 596 patients who underwent endo-DCR over a 30-year period (1989-2018). Patients' demographics and surgical techniques were assessed. Among the cohort of patients (n = 478) who underwent primary endo-DCR, 10% (n = 48) required revision surgery. Patients who failed primary DCR tended to be younger (p = 0.015) and were less likely to have chronic sinonasal inflammation on histopathology (p = 0.047) than the successful surgery group. After adjusting for patient demographics and comorbidities, the occurrence of a postoperative complication was significantly associated with primary DCR failure (odds ratio [OR], 2.2; p = 0.032). Among the cohort of patients (n = 118) who underwent revision endo-DCR, 8.5% (n = 10) required additional revision surgery. Patients who failed revision DCR tended to be younger (p = 0.022), more likely to have had intraoperative laser usage (p = 0.031), and more likely to have had an intraoperative complication (p = 0.013) than the successful revision surgery group. Endo-DCR failure was not associated with smoking status, middle turbinate resection, or intraoperative visualization of the internal common punctum (p > 0.05). An understanding of factors associated with primary and revision endo-DCR failure can help to inform preoperative counseling, intraoperative surgical technique, and postoperative care in the treatment of patients with nasolacrimal duct obstruction.

Complications Are Rare From Middle Turbinate Resection: A Prospective Case Series

Background When chronic rhinosinusitis with nasal polyps (CRSwNP) fails to respond to medical therapy, endoscopic sinus surgery (ESS) plays an integral role in management. Some studies have shown that middle turbinate resection (MTR) during ESS leads to decreased polyp recurrence and revision ESS rates. Other studies suggest MTR can lead to complications. Objective The purpose of this study was to assess the safety of MTR during ESS for CRSwNP by determining the incidences of intraoperative cerebrospinal fluid (CSF) leak, postoperative epistaxis requiring operative intervention, and postoperative complete frontal stenosis. Methods A multiinstitutional, prospective case series of 91 adult CRSwNP patients was conducted. Patients with medically refractory CRSwNP underwent primary or revision ESS plus MTR by 3 surgeons. Two of the surgeons performed partial MTRs, and one of the surgeons performed complete MTRs. Patients were evaluated for the following complications: intraoperative CSF leak during MTR, postoperative epistaxis requiring operative intervention, and postoperative complete frontal ostial stenosis. Secondary outcomes included changes from preoperative to postoperative 22-item Sinonasal Outcome Test (SNOT-22) scores and revision ESS rates. Results Unilateral or bilateral complete ESSs with MTRs were performed on 91 CRSwNP patients. In total, 173 MTRs were performed. Two surgeons performed 97 partial MTRs on 49 patients, and the third surgeon performed 76 complete MTRs on 42 patients. One CSF leak occurred during partial MTR (1/173, 0.57%). No patients suffered postoperative epistaxis requiring operative intervention, and no patients developed complete frontal stenosis. From preoperatively to postoperatively, mean SNOT-22 scores decreased from 53.7 to 13.1 ( P = .001). No revision ESS was needed during the follow-up period. Mean follow-up time was 7.5 ± 5.4 months. Conclusions Partial and complete MTR during ESS for CRSwNP in this cohort resulted in very low, acceptable intraoperative and short-term postoperative complication rates and no detriment to SNOT-22 scores.

Central compartment involvement in aspirin-exacerbated respiratory disease: the role of allergy and previous sinus surgery.

Evidence for a relationship between allergy and chronic rhinosinusitus with nasal polyps (CRSwNP) is equivocal. Central compartment (CC) atopic disease is a nasal inflammatory condition related to inhalant allergy. CC involvement is common in aspirin-exacerbated respiratory disease (AERD), a subset of CRSwNP, and we hypothesize it is related to allergic status. This study was a retrospective analysis of a single-institution database for the January 2016 to February 2019 time period. Data regarding endoscopic CC findings, clinical allergy history, and results of allergy testing were collected. Statistical analysis was performed, with significance set at p < 0.05. Seventy-two AERD patients met the inclusion criteria. Fifty-nine patients had CC involvement (53 bilateral, 6 unilateral). For patients with documented allergy status, 100% of patients with endoscopic CC disease had clinical allergic rhinitis (AR), and 45 of 48 (93.8%) had positive allergy testing. Thirteen patients had no CC involvement (4 with clinical AR; 3 of 7 with positive allergy testing). CC endoscopic findings in AERD were significantly associated with clinical allergy (p < 0.0001, phi = 0.771). Overall, patients with CC involvement averaged 3.8 surgeries vs 3.2 for those without CC involvement (p = not statistically significant). However, patients with septal involvement averaged 4.2 surgeries vs 2.0 for those without septal involvement (p = 0.004). As the number of sinus surgeries increases, middle turbinate (MT) resection (r = 0.300, p = 0.022) and septal involvement (r = 0.372, p = 0.004) significantly increase. All patients with MT resection had septal disease, whereas none without CC disease had MT resection. Most AERD patients exhibit AR, and this correlates with CC disease. As the number of surgeries increases, MT resection may predispose to polyposis of the septum.

No Difference in Clinical Outcome between Middle Turbinate Resection vs Inferior Turbinoplasty in Patients with Rhinitis

No Difference in Clinical Outcome between Middle Turbinate Resection vs Inferior Turbinoplasty in Patients with Rhinitis

Impact of Middle Turbinectomy on Airflow to the Olfactory Cleft: A Computational Fluid Dynamics Study.

The impact of middle turbinate resection (MTR) on olfaction remains a point of debate in the current literature. Few studies have objectively evaluated olfactory cleft airflow following MTR; thus, the mechanism by which MTR may impact olfaction is poorly understood. It is not known whether the postsurgical changes in airway volume, flow, and resistance increase odorant transport or disrupt the patterns of normal airflow. Computational fluid dynamics can be used to study the nasal airway and predict responses to surgical intervention. To evaluate the functional impact of MTR on nasal airflow, resistance, and olfaction. Five maxillofacial computed tomography scans of patients without signs of significant sinusitis or nasal polyposis were used. Control models for each patient were compared to their corresponding model after virtual total MTR. For each model, nasal airway volume, nasal resistance, and air flow rate were determined. Odorant transport of 3 different odorants in the nasal cavity was simulated based on the computed steady airflow field. Total airflow significantly increased following bilateral MTR in all patient models ( P < .05). Consistent with our airflow results, we found a decrease in nasal resistance following MTR. MTR significantly increased area averaged flux to the olfactory cleft when compared to controls for phenylethyl alcohol (high-sorptive odorant). Results for carvone (medium sorptive) were similarly elevated. MTR impact on limonene, a low flux odorant, was equivocal. MTR increases nasal airflow while decreasing the nasal resistance. Overall, olfactory flux increased for high sorptive (phenylethyl alcohol) and medium sorpitve (l-carvone) odorants. However, the significant variation observed in one of our models suggests that the effects of MTR on the nasal airflow and the resultant olfaction can vary between individuals based on individual anatomic differences.

Computational fluid dynamics after endoscopic endonasal skull base surgery-possible empty nose syndrome in the context of middle turbinate resection.

Empty nose syndrome (ENS) is a rare and debilitating disease with a controversial definition, etiology, and treatment. One puzzling fact is that patients who undergo an endoscopic endonasal approach (EEA) often have resection of multiple anatomic structures, yet seldom develop ENS. In this pilot study, we analyzed and compared the computational fluid dynamics (CFD) and symptoms among post-EEA patients, ENS patients, and healthy subjects. Computed tomography scans of 4 post-EEA patients were collected and analyzed using CFD techniques. Two patients had significant ENS symptoms based on results of the Empty Nose Syndrome 6-item Questionnaire (score >11), whereas the other 2 were asymptomatic. As a reference, their results were compared with previously published CFD results of 27 non-EEA ENS patients and 42 healthy controls. Post-EEA patients with ENS symptoms had a similar nasal airflow pattern as non-EEA ENS patients. This pattern differed significantly from that of EEA patients without ENS symptoms and healthy controls. Overall, groups with ENS symptoms exhibited airflow dominant in the middle meatus region and a significantly lower percentage of airflow in the inferior turbinate region (EEA with ENS, 17.74 ± 4.00% vs EEA without ENS, 51.25 ± 3.33% [t test, p < 0.02]; non-EEA ENS, 25.8 ± 17.6%; healthy subjects, 36.5 ± 15.9%) as well as lower peak wall shear stress (EEA with ENS, 0.30 ± 0.13 Pa vs EEA without ENS, 0.61 ± 0.03 Pa [p = 0.003]; non-EEA ENS, 0.58 ± 0.24 Pa; healthy subjects, 1.18 ± 0.81 Pa). These results suggest that turbinectomy and/or posterior septectomy may have a varying functional impact and that ENS symptoms go beyond anatomy and correlate with aerodynamic changes. The findings open the door for CFD as a potential objective diagnosis tool for ENS.

Endoscopic Endonasal Transmaxillary Transsphenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video.

We present a 43-old-male who suffered from a slowly progressive loss of vision in the left eye. Magnetic resonance (MR) imaging revealed a well-circumscribed contrast-enhancing lesion in the region of the anterior cavernous sinus and superior orbital fissure that extended into the optic canal. A schwannoma or meningioma was suspected. A transcranial surgery performed at another institution was not successful in removing the tumor and further deterioration of vision occurred. After resection of the left middle turbinate, the sphenoid and maxillary sinus were opened. The bulging of the tumor was seen at the lateral wall of the sphenoid sinus. After bony decompression of the optic canal, the dura was opened. A meningioma was exposed that arose in between the dural layers of the cavernous sinus. A nice dissection plane was found and the tumor was circumferentially dissected and finally totally removed. There were no complications such as double vision or visual field deficit. MR imaging confirmed a total tumor resection. The visual acuity normalized within a few days. MR imaging obtained 3 yr after surgery shows no recurrence.

Functional Endoscopic Sinus Surgery of Nasal Polyposis: The Vexing Question of Whether to Resect or Preserve Middle Turbinate.

Functional endoscopic sinus surgery is the mainstay of surgical management of nasal polyposis since 1975. The decision between the partial resection and preservation of the middle turbinate (MT) has stirred up considerable debate. Partial MTR permits easy access to the affected paranasal sinuses intraoperatively and postoperatively. However, there may be alteration of nasal function, frontal sinusitis and anosmia. Preservation of middle turbinate is precludes these complications, and allows the MT to serve as a vital anatomical landmark for revision surgery. Therefore, our study compared the outcomes of the two approaches to aid surgeons in deciding the best possible approach. Randomized control trial. 31 patients (60 sides of nasal cavity) with nasal polyposis were divided into two groups. Group I consisted of 30 sides of nasal cavity with middle turbinate resection, while group II consisted of 30 sides of nasal cavity without middle turbinate resection. Both the groups were compared postoperatively for 6months. In group I and group II, 5 sides (16.6%) and 11 sides (36.6%) showed polypoidal changes respectively. 3 sides (10%) in group I and 8 sides (26.6%) in group II showed blockage of maxillary sinus ostia. All the sides in group I had patency of frontal sinus. In group II, 5 sides (16.6%) showed blockage of frontal sinus ostia. The maxillary antrostomy patency in group I and group II were 90% (27) and 73.33% (22) respectively. Assessment of symptomatic improvements for nasal obstruction, hyposmia, headache and rhinorrhoea was done using questionnaires. Symptomatic improvement was higher in group I compared to group II with statistical significance (p = 0.001). Our study demonstrated that partial resection of middle turbinate decreased the chances of recurrence of disease and post-operative complications and resulted in significantly better symptomatic improvements.

Partial resection of the middle turbinate during endoscopic sinus surgery for chronic rhinosinusitis does not lead to an increased risk of empty nose syndrome: a cohort study of a tertiary practice.

The treatment of the middle turbinate (MT) during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) remains a contentious issue with arguments both for and against its resection. The purpose of this study was to examine the clinical impact of partial MT resection (PMTR) during ESS, paying particular attention to the risk of developing empty nose syndrome (ENS) and alteration to olfaction. This cohort study was performed on prospectively collected data. A total of 177 patients underwent ESS for CRS; 93 had PMTR and 84 MT preservation (MTP). Preoperative data collection included subjective symptom scores as per the Adelaide Disease Severity Score (ADSS), Lund-Mackay scores, and nasal polyp status. The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) was administered by telephone consultation and analyzed alongside postoperative symptom scores. There was no difference in ENS6Q scores in patients who underwent PMTR vs those who had MTP. Patients who underwent PMTR had a higher baseline disease on Lund-Mackay scoring, and were more likely to be nasal polyp patients and be undergoing revision surgery. ADSS scores demonstrated significant improvements in all rhinologic symptoms, with no difference between the cohorts. PMTR is an adjunctive procedure to ESS. This study has established that PMTR as performed by the senior author carries no additional risk of developing ENS symptoms as defined by the ENS6Q, and that it carries no additional risk to olfaction or other rhinologic symptoms. PMTR can be safely considered at time of ESS, especially in patients at risk of lateralization of the MT.

The Middle Turbinate Resection and Its Repercussion in Olfaction with the University of Pennsylvania Smell Identification Test (UPSIT).

Introduction Nasal obstruction is a common complaint, and, for some, the middle turbinate resection is still a controversial issue among the surgical options due to the possibility of deleterious effects on olfaction. The University of Pennsylvania smell identification test (UPSIT) is considered the gold standard of smell identification tests, but data about it is still incipient in Brazil. Objective To evaluate if the middle turbinectomy has any repercussion on the sense of olfaction by using the UPSIT as an assessment tool. Methods A prospective study performed between 2013 and 2015 with 27 patients who were treated with middle turbinectomy by the same surgeon and tested with the UPSIT pre- and post-surgery, with a minimum interval of 3 months. Results Twenty-five patients completed the study. The mean age was 27.9 years. There was no statistical correlation between middle turbinectomy and the UPSIT score, or between gender and the UPSIT score. Conclusion There was no clinical repercussion on olfaction from partial middle turbinectomy.

Does the Timing of Middle Turbinate Resection Influence Quality-of-Life Outcomes for Patients with Chronic Rhinosinusitis?

Objective To evaluate the impact of bilateral middle turbinate resection (BMTR) on patient-reported quality of life following primary and revision endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Study Design Prospective cohort study. Setting Tertiary care center. Subjects and Methods Patients with CRS who were recruited from 11 otolaryngologic practices completed the Sino-Nasal Outcome Test-22, Chronic Sinusitis Survey, and EuroQol 5-Dimension questionnaires at baseline, as well as 3 and 12 months after ESS. In the primary ESS cohort (n = 406), patients who underwent BMTR (n = 78) at the time of surgery were compared with patients (n = 328) whose middle turbinates were preserved. In the revision ESS cohort (n = 363), a similar comparison was made between patients who did (n = 64) and did not (n = 299) undergo BMTR. Results Sino-Nasal Outcome Test-22, Chronic Sinusitis Survey, and EuroQol 5-Dimension scores showed similar improvements for both the turbinate resection and preservation cohorts at 3 months ( P < .001) and 12 months ( P < .001) after surgery. For patients who underwent revision surgery, the performance of BMTR resulted in greater improvement in Chronic Sinusitis Survey scores at 1 year as compared with the turbinate preservation group (change from baseline: 28.1 vs 20.7, respectively; P = .026). History of tobacco use and the presence of nasal polyps did not affect clinical outcomes at any time point. Conclusion Patients who underwent BMTR during primary and revision sinus surgery reported similar benefits in quality-of-life outcomes 1 year after surgery. In select patients undergoing revision sinus surgery, the performance of BMTR results in improved disease-specific quality of life.

Evaluation of the effect of partial middle turbinate resection on the olfactory function

Evaluation of the effect of partial middle turbinate resection on the olfactory function

Improved delivery of sinus irrigations after middle turbinate resection during endoscopic sinus surgery.

Improvement in topical delivery to nasal mucosa is a fundamental goal of endoscopic sinus surgery (ESS). This study compares the penetration of irrigation before and after middle turbinate resection (MTR) to assess the efficacy of topical delivery. ESS was performed on 4 cadaver heads, followed by MTR. Each head was irrigated with fluorescein-dyed water using a squeeze bottle both before and after MTR. Videos were recorded by rigid nasal endoscopy. Four blinded raters reviewed videos and scored the extent of staining (0 to 3) for each site. The mean score for the extent of staining of all anatomical sites before and after MTR was 1.30 and 1.92, respectively (p = 0.035). The mean score for extent of staining before and after MTR was 2.56 and 2.81 (p = 0.134) for the maxillary sinus, 1.66 and 2.25 (p = 0.022) for the ethmoid sinus, 1.03 and 1.94 (p = 0.263) for the sphenoid sinus, 0.16 and 0.94 (p = 0.055) for the frontal sinus, and 1.09 and 1.66 (p = 0.340) for the olfactory cleft, respectively. When evaluating interrater reliability, Cronbach's alpha was 0.92, which is acceptable. When evaluating intrarater reliability, the Fleiss kappa statistic for each rater was excellent or good. Overall, MTR results in significant improvement in the penetration of nasal irrigations in the cadaver model. Each individual sinus displays a trend toward improvement; however, only the ethmoid sinus displays a statistically significant improvement. Further in vivo studies are needed to elucidate the role of MTR.

Effects of partial middle turbinectomy with varying resection volume and location on nasal functions and airflow characteristics by CFD

The surgical term "turbinectomy" encompasses many variations in the location and extent of removal. As a systemic approach to consider the negative impact of middle turbinectomy(MT), such as the excessive removal of turbinate, airflows inside a pre-surgery model and a series of virtual surgery models were numerically analyzed and compared. These models simulate three variations of partial MT(three bilateral and three unilateral) with varying resection volume and location. Each middle turbinectomy results in alterations of flow and thermal parameters, such as nasal resistance (NR), velocity, temperature, wall shear stress(WSS) and wall heat transfer(WHT). WSS distributions were also considered in connection with mucosal secretion. The tendency of changes in nasal functions and airflow characteristics was identified with respect to resection volume and location. A counter-rotating vortical structure was seen in the region of widened middle airway for the case of total resection of middle turbinate. Maximum velocity and WSS near sphenopalatine ganglion, which was a possible explanation for headache after total resection of middle turbinate, was increased. Changes in NR and WHT for bi-lateral resection cases were greater than those for unilateral resection cases. While the physiological changes in four partial MT models were insignificant, changes in near total resection model was prominent. Although our surgical simulation was done for a single case, we postulate that the removal of the anterior inferior part of middle turbinate while preserving posterior margin will not alter airflow characteristics extensively. These findings will help designing surgical plans for partial MT.

Empty nose syndrome: etiopathogenesis and management

Empty nose syndrome (ENS) is an iatrogenic disorder most often recognized by the presence of paradoxical nasal obstruction despite an objectively wide patent nasal cavity. It occurs after inferior and/or middle turbinate resection; however, individuals with normal turbinates and intranasal volume may also complain of ENS. Its pathophysiology remains unclear, but it is probably caused by wide nasal cavities affecting the neurosensitive receptors and inhaled air humidification. Neuropsychological involvement is also suspected. Not every patient undergoing radical turbinate resection experiences the symptoms of ENS. ENS can affect the normal breathing function of the nasal cavity, with subsequent deterioration in patients’ quality of life. The diagnosis is made on the basis of the patients’ history, endoscopic examination of the nasal cavity, imaging (computed tomography imaging and functional MRI), and rhinomanometry. Prevention is the most important strategy; thus, the inferior and middle turbinate should not be resected without adequate justification. Management is problematic including nasal cavity hygiene and humidification, with surgery reserved for the most severe cases. The surgery aims at partial filling of the nasal cavity using different techniques and implant materials. In this paper, we review both the etiology and the clinical presentation of ENS, and its conservative and surgical management. Empty nose syndrome (ENS) is encountered after inferior and/or middle turbinate resection; however, it can occur in patients with seemingly normal turbinates. Rhinologists should avoid routine resection of the inferior and middle turbinates. It is not certain why some patients develop ENS, whereas others do not. The frequent association with psychiatric disorders and possibly psychosomatic pathologies indicate the possible role of psychological stress in some patients. Its diagnosis relies on clinical suspicion and physical examination. Nasal augmentation surgery can improve the quality of life of patients by restoring nasal anatomy toward the premorbid state.

The effect of middle turbinate resection on topical drug distribution into the paranasal sinuses.

During sinus surgery, partial or complete resection of the middle turbinate (MT) is sometimes necessary because of polypoid changes or demineralization. Topical drug delivery to the paranasal sinuses is an integral component in managing chronic rhinosinusitis (CRS) with and without nasal polyposis. The purpose of this study was to examine the role of the MT and MT resection in topical drug distribution into the sinuses via nebulization. We report on a novel technique of quantitatively evaluating the delivery of nebulized dye in cadavers. Endoscopic sinus surgery was performed on 5 fresh cadavers. Complementary colored dyes mixed with saline were successively nebulized using the following protocol: (1) fluorescein prior to MT resection; (2) brilliant green following partial MT resection; and (3) methylene blue following total MT resection. Photodocumentation of the sinuses was performed following each nebulization and standardized photoanalysis was performed. Successive nebulizations with fluorescein, brilliant green, and methylene blue produced a complementary staining pattern that provided an easy side-by-side analysis of the extent of mucosal staining. Dye delivery to the frontal and sphenoid sinuses significantly increased following partial resection of the MT (p = 0.013 and p = 0.0027, respectively) and complete resection of the MT (p = 0.027 and p = 0.027, respectively). Following complete MTR, dye delivery to the maxillary sinus significantly increased compared to baseline (MT intact) (p = 0.0027). Resection of the MT appears to have a significant effect on nebulized drug delivery into the frontal, maxillary, and sphenoid sinuses. Future prospective studies will help delineate the clinical relevance of this effect.

Bleeding risk associated with resection of the middle turbinate during functional endoscopic sinus surgery.

The decision to resect the middle turbinate (MT) during functional endoscopic sinus surgery is controversial. Although there have been a variety of studies that examined the functional outcome related to this maneuver, very few studies evaluated the potential for complications, in particular, epistaxis. We sought to determine if resection of the MT during functional endoscopic sinus surgery leads to an increased risk for postoperative bleeding. Patients who underwent functional endoscopic sinus surgery for chronic sinusitis or nasal polyposis between 2004 and 2014 at a single institution were analyzed for bleeding and other complications after resection of the MT. Between 2004 and 2014, 1185 sinus surgeries were performed by 18 surgeons. A propensity matched set of 228 patients who underwent turbinate resection, and 228 controls were selected based on predicted probabilities from a logistic regression that predicted turbinate resection and that was adjusted for age, sex, and procedure. There were 89 patients with bilateral turbinates removed and 139 with unilateral turbinates removed. There was no significant difference in major bleeding or other complication rates between the two groups. Patients who underwent resection of at least one MT were 3.95 times more likely to have minor bleeding compared with those who did not; this risk increased with the number of turbinates resected (trend p = 0.008). Patients on anticoagulation medications were at a significant risk of bleeding if their MT was removed (p = 0.007), whereas patients on aspirin or antiplatelet therapy were not at a significant risk. There was no increased risk of major bleeding or other complication associated with resection of the MT. However, there was a significantly increased minor bleeding rate associated with MT resection, particularly if the patient was on anticoagulants.