Middle turbinate preservation versus middle turbinate resection in endoscopic surgical treatment of nasal polyposis

Prognostic Value of Polypoid Changes of the Middle Turbinate in Relapsed Nasal Polypi after FESS: A Prospective Cohort Study

Introduction  Despite the high level of patient satisfaction with functional endoscopic sinus surgery (FESS) and the clinical improvement, polyp recurrence is observed in 23% to 87% of patients and requires reoperation. Objective  To assess the prognostic value of polypoid changes of the middle turbinate (PCMT) in relapse of paranasal sinus polyps in patients with chronic rhinosinusitis with nasal polyp (CRSwNP) after FESS and the effect of partial middle turbinectomy (PMT) on the outcome of surgery. Methods  We conducted a prospective clinical study on 60 patients with CRSwNP with and without PCMT. The patients were allocated into three groups: group I included twenty patients without PCMT; group II, twenty patients with PCMT; and group III included twenty patients with PCMT submitted to PMT. The patients were evaluated endoscopically according to the Lund-Kennedy endoscopic scoring system, radiologically according to the Lund-Mackay scoring system, and symptomatically through the 22-item Sinonasal Outcome Test (SNOT-22). Results  The total postoperative Lund-Kennedy score differed significantly among the 3 groups ( p  < 0.001), with a group II presenting a significantly higher total score compared to groups I and III. The Preoperative SNOT-22 score differed significantly among the three groups ( p  = 0.013), with group II presenting a significantly higher score compared to group I. There was a significant association involving the 3 groups and relapse at 12 months ( p  = 0.029); relapse was higher in group II (50.0%) than in groups I (20%) and III (15.0%). Conclusion  There was a significant association between PCMT and the relapse of nasal polyps. Also, nasal polyposis recurred at a lower rate in the group submitted to middle turbinate resection compared to the group in whom it was preserved.

Medial flap middle turbinoplasty for solid middle turbinate hypertrophy: improving airway, speeding healing and preserving olfaction

PURPOSE

The techniques to be performed for bullous middle turbinates are well-defined and widely accepted in the literature. However, in the case of solid middle turbinate hypertrophy, information on surgical techniques that take into account function and sense of smell is very limited in the literature. The aim of this study was to compare the airway patency and olfaction results of patients diagnosed with solid middle turbinate hypertrophy, who underwent subtotal (transverse) resection or medial flap turbinoplasty of the middle turbinates.

METHODS

Thirty-five adult patients who were diagnosed with solid middle turbinate hypertrophy were divided into two groups, namely medial flap middle turbinoplasty (study group = 17) and transverse resection to the middle turbinate (control group = 18). Acoustic rhinometry, anterior rhinomanometry, peak nasal inspiratory flowmeter test, odor identification test, and n-butanol threshold measurements were performed before and 3 months after the surgery. In addition, preoperative and postoperative nasal obstruction and olfactory senses of the patients were evaluated with visual analog scale and nasal obstruction symptom evaluation scale.

RESULTS

Visual analog scores for olfaction were significantly higher in the study group compared to the control group. In odor identification test, a significant improvement was observed in the study group, while a decrease was observed in the control group. While there was a decrease in the n-butanol thresholds values in the study group, there was an increase in the control group.

CONCLUSIONS

Medial mucosal flap technique is an effective and functional turbinoplasty technique that can be used in solid hypertrophy of the middle turbinate, which offers advantages in terms of enhanced airway healing and olfactory results.

Maximizing Postoperative Recovery: The Role of Functional Biomaterials as Nasal Packs-A Comprehensive Systematic Review without Meta-Analysis (SWiM)

Numerous biomaterials have been developed over the years to enhance the outcomes of endoscopic sinus surgery (ESS) for patients with chronic rhinosinusitis. These products are specifically designed to prevent postoperative bleeding, optimize wound healing, and reduce inflammation. However, there is no singular material on the market that can be deemed the optimal material for the nasal pack. We systematically reviewed the available evidence to assess the functional biomaterial efficacy after ESS in prospective studies. The search was performed using predetermined inclusion and exclusion criteria, and 31 articles were identified in PubMed, Scopus, and Web of Science. The Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess each study's risk of bias. The studies were critically analyzed and categorized into types of biomaterial and functional properties, according to synthesis without meta-analysis (SWiM) guidelines. Despite the heterogeneity between studies, it was observed that chitosan, gelatin, hyaluronic acid, and starch-derived materials exhibit better endoscopic scores and significant potential for use in nasal packing. The published data support the idea that applying a nasal pack after ESS improves wound healing and patient-reported outcomes.

Guanti bianchi technique for resection of selected pituitary adenomas

Introduction

Since the introduction of the endoscopic endonasal approach (EEA) to skull base, the nasal phase has been a true challenge as it represents the moment of definition of the corridor, thus defining the instruments maneuverability at tumor removal phase. The longstanding cooperation between ENT and neurosurgeons have provided the possibility of creating adequate corridor with maximal respect toward nasal structures and mucosa. This sparked the idea of entering the sella as thieves, so we named "Guanti Bianchi" technique a lesser invasive variation of the approach for the removal of selected pituitary adenoma.

Research Question

The purpose of this study is to present the preliminary results of "Guanti Bianchi" technique.

Material and Methods

Data from 17 patients undergoing "Guanti Bianchi" technique (out of 235 standard EEA) at our center, were retrospectively analysed. ASK Nasal-12, a quality-of-life instrument developed specifically to assess patient perception of nasal morbidity, was administered pre- and postoperatively.

Results

10 (59%) patients were men and 7 (41%) women. The mean age was 67.7 (range 35-88). The average duration of the surgical procedure was 71.17 minutes (range 45-100). GTR was achieved in all patients, no postoperative complications were observed. Baseline ASK Nasal-12 was near normal in all patients, 3/17 (17,6%) experienced transitory very mild symptoms without any worsening at 3 and 6 months.

Discussion and Conclusions

This minimally invasive technique does not require turbinectomy or carving of the nasoseptal flap, it alters the nasal mucosa as little as necessary, and it is quick and easy to perform.

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

BACKGROUND

Frontal 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 METHODS

This 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.

RESULTS

The 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*).

CONCLUSION

Partial 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.

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

PURPOSE

Empty 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 METHODS

This 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.

RESULTS

Pathologies 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.

CONCLUSIONS

Patients 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.

The impact of bolgerization versus partial resection of the middle turbinate on frontal sinusotomy patency outcome: A randomised controlled study

OBJECTIVES

This study aimed to compare the effects of middle turbinate resection vs bolgerization on the incidence of middle meatus synechia and their prognostic value on the patency outcomes after frontal sinusotomy.

DESIGN

A randomised controlled study.

SETTING

Tertiary centre hospital.

MAIN OUTCOME MEASURES

Thirty-eight patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis were included. Partial middle turbinate resection was alternated with bolgerization in both nasal cavities of every patient. The Lund-Kennedy endoscopic scores (LKESs) for both sides were compared at the first, third and sixth months postoperatively. Middle meatus synechia was assessed using the visual analogue score (VAS). Sinus patency was assessed at the end of the sixth month using a 70° nasal endoscope.

RESULTS

The sinus patency outcome was significantly higher in the resected group (34\38) than the bolgerized group (26\38), (P = .047*). The VAS scores suggested that the middle turbinate bolgerization group showed a significantly higher incidence of middle meatal synechia than the partial middle turbinate resection group (4.47 ± 2.617 vs 3.29 ± 2.301; P = .040*).

CONCLUSION

Middle turbinate resection showed more favourable results than bolgerization concerning the sinus patency outcome after frontal sinusotomy. It also showed a lower incidence of middle meatus synechia postoperatively.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

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.

Resection versus preservation of the middle turbinate in surgery for chronic rhinosinusitis with nasal polyposis: a randomized controlled trial

Background

Chronic rhinosinusitis (CRS) affects up to 16% of the population. When medical treatment fails, endoscopic sinus surgery (ESS) is considered. The value of resecting the middle turbinate to optimize surgical outcomes has been hypothesized but remains controversial and unproven. Whether the middle turbinate should be left in place or resected is controversial. Our objective is to determine if middle turbinectomy improves objective surgical outcomes after ESS.

Methods

Sixteen patients (15 men, 15 primary surgery) undergoing bilateral complete ESS for CRS with nasal polyposis were recruited. Nasal cavities were randomized so that middle turbinectomy was performed on one side while the middle turbinate was preserved on the other. Each participant acted as their own control. Nasal cavities were compared using Perioperative Sinus Endoscopy (POSE) and Lund-Kennedy (LKES) scores pre-operatively, and at 1, 3 and 6 months after ESS. Results were analyzed using Wilcoxon signed-rank test.

Results

Pre-operatively, the POSE (12.4 ± 2.9 vs 12.8 ± 2.6, p = 0.33, for the preserved side and the resected side, respectively) and LKES (5.0 ± 1.0 vs 4.8 ± 1.2, p = 0.33) scores were similar between sides. During follow up, resection was associated with more crusting at 1 month following ESS (1.0 ± 0.7 vs 0.4 ± 0.6, p = 0.02). There was a small, but statistically significant, difference between the nasal cavities at 3 months, where the resected side showed better endoscopic appearance (2.0 ± 2.2 vs 3.4 ± 2.8, p = 0.01). No difference was found at 6 months. Frontal sinus scores were similar between sides at 6 months (0.7 ± 0.5 vs 0.7 ± 0.5, p = 1.00).

Conclusion

Our results show no sustained objective endoscopic benefit of routine middle turbinectomy, at least within the first six postoperative months, in patients undergoing primary ESS for CRS with polyposis.

Trial registration

NCT, NCT02855931. Registered 16 August 2016.

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 6 months. 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.

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis

OBJECTIVE

To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management.

METHODS

Longitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed.

RESULTS

The frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement.

CONCLUSIONS

Our long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions.

Endoscopic unilateral transethmoid-paraseptal approach to the central skull base

Objectives

The endoscopic technique in transnasal skull base surgery offers optimal visualization and free manipulation in the surgical field. However, it may cause approach‐related sinonasal injury, influencing patients' quality of life (QOL). To minimize rhinological morbidity without restrictions in surgical manipulation and tumor resection, we introduced the unilateral transethmoidal‐paraseptal approach. In this article, we analyzed the long‐term results and sinonasal outcome of this technique.

Study Design

Retrospective analysis of medical records.

Methods

Forty‐two consecutive patients underwent surgery between June 2010 and March 2014 using the transethmoid‐paraseptal approach. Perioperative work‐up included neurological, radiological, endocrinological, ophthalmological, and rhinological analysis. Patients' preoperative, 1‐month and 1‐year postoperative QOL was measured using the Sino‐Nasal Outcome Test (SNOT‐22).

Results

At all individuals, a unilateral transethmoid‐paraseptal approach was performed. Removal of the turbinates, posterior septal resection or a conversion to biportal surgery could be avoided in all cases. There were no intraoperative neurovascular complications. All patients had a notable improvement in any disease‐related symptoms, as well as by objective criteria. Complete tumor resection was aimed in 39 cases and achieved in 31 of them. The SNOT‐22 scores transiently worsened 1 month after surgery and non‐significantly improved after 1 year, compared with the preoperative status. A subgroup of 7 patients with preoperative sinonasal disease evidence showed continuous significant improvement (p < .05) of SNOT‐22 scores across time. The smell screening tests showed no significant difference across time.

Conclusion

The described approach allows safe removal of various skull base lesions without deterioration in sinonasal QOL and smell function.

Level of Evidence

4.

How I do it: the mononostril endonasal transethmoidal-paraseptal approach

BACKGROUND

The use of endoscopes in transnasal surgery offers increased visualization. To minimize rhinological morbidity without restriction in manipulation, we introduced the mononostril transethmoidal-paraseptal approach.

METHODS

The aim of the transethmoidal-paraseptal approach is to create sufficient space within the nasal cavity, without removal of nasal turbinates and septum. Therefore, as a first step, a partial ethmoidectomy is performed. The middle and superior turbinates are then lateralized into the ethmoidal space, allowing a wide sphenoidotomy with exposure of the central skull base.

CONCLUSIONS

This minimally invasive transethmoidal-paraseptal approach is a feasible alternative to traumatic transnasal concepts with middle turbinate and extended septal resection.

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

BACKGROUND

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.

OBJECTIVE

We sought to determine if resection of the MT during functional endoscopic sinus surgery leads to an increased risk for postoperative bleeding.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Extensive versus functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps and asthma: A 1-year study

BACKGROUND

Functional endoscopic sinus surgery (FESS) is considered to be the standard procedure for chronic rhinosinusitis with nasal polyps (CRSwNP). However, for CRSwNP that accompanies asthma, the results are not satisfying. Extensive endoscopic sinus surgery (EESS) aimed at reducing the inflammatory load has been indicated as a viable option for refractory chronic rhinosinusitis.

OBJECTIVE

To evaluate the clinical outcomes and safety of EESS (middle turbinate and superior turbinate resection and total ethmoidectomy) for patients with CRSwNP and with asthma.

METHODS

This was a prospective, single-institute cohort study conducted in a tertiary teaching hospital. Patients with CRSwNP and with asthma who were proceeding to surgery were enrolled. There were 23 patients in the EESS group and 24 patients in the FESS group. The preoperative disease severity was evaluated by the visual analog scale (VAS), Lund-Kennedy (L-K) endoscopy score, computed tomography Lund-Mackay score, asthma control test (ACT), and pulmonary function test. Clinical outcomes were comparatively evaluated between the two groups after a 1-year follow-up by using the VAS score, the postoperative endoscopic score (E score), L-K score, ACT score, and pulmonary function test.

RESULTS

The disease severity (general VAS score, endoscopic L-K score, computed tomography score, ACT score) showed no significant differences between the two groups before surgery (p > 0.05). One year after surgery, both groups achieved significant improvement in the VAS score and endoscopic L-K score. The EESS group showed better improvement in the olfactory VAS score and E score compared with the FESS group (mean [standard deviation] change of olfactory VAS, 6.00 ± 3.67 versus 3.30 ± 3.44, p = 0.015; mean [standard deviation] E score, 0.31 ± 0.18 versus 0.66 ± 0.26, p < 0.001). No significant differences were found in the change of general nasal symptom VAS score, other individual VAS scores (nasal congestion, discharge, headache and/or facial pain), L-K score, ACT score, and pulmonary function between the two groups (p > 0.05).

CONCLUSION

EESS for patients with CRSwNP and with asthma may help to improve the subjective olfaction and endoscopic appearance.

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.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Refinement of the nasalisation technique for nasal polyposis

BACKGROUND

Radical ethmoidectomy for nasal polyposis (nasalisation) tends to offer better results than functional ethmoidectomy in terms of recurrence. We have been performing the nasalisation technique since 2004, but late complications such as mucoceles were noted in several patients. We implemented some modifications to the nasalisation technique in order to reduce the complication rate while obtaining a similar recurrence rate.

METHODOLOGY AND PRINCIPAL

Retrospective study on the files of patients operated for diffuse nasal polyposis after 24months of follow-up. Group A included 45 patients (90 sides) operated with the classical nasalisation technique, and group B included 74 patients (148 sides) operated with the modified technique.

RESULTS

Preoperative endoscopic grading results did not show any significant difference between groups. Recurrence rates at 24months of postoperative follow-up were of 22.2% and of 18.9% for group A and B respectively. This difference was not statistically significant. Complication rates were of 37.8% and 8.8% for Group A and Group B respectively. Complication rate was significantly lower for group B (P=0.002, standard deviation of 0.467).

CONCLUSIONS

The modified nasalisation technique offers the same functional results than the classical technique, but with a significant reduction of the late complication rate.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Clinical effects of middle turbinate resection after endoscopic sinus surgery: a systematic review

BACKGROUND

The middle turbinate (MT) is a structure that is often carefully preserved during endoscopic sinus surgery (ESS) in an effort to preserve nasal physiology and serve as an anatomic landmark. However, resection is performed in select cases because of involvement of the MT in the inflammatory process, obstruction, or instability. Therefore, significant controversy exists among surgeons regarding the indications for proceeding with MT resection in ESS. This study evaluates clinical outcomes of MT resection after ESS.

METHODS

An English language search of the PubMed and Ovid databases was conducted for publications examining clinical outcomes of MT resection after ESS performed for chronic rhinosinusitis. Two authors independently examined the articles to identify those meeting inclusion criteria. Any differences over which studies to include were resolved by discussion and consensus. Bias assessment was conducted using the Cochrane Collaboration bias tool for randomized controlled trials and the Newcastle-Ottawa bias tool for cohort and case-control studies.

RESULTS

After initial screening, search results revealed 71 articles that warranted detailed evaluation. After applying inclusion criteria, 9 studies were selected. A total of 2123 patients were included among the studies. All studies were controlled. Within the limited available data, olfaction scores may be improved in the MT resection patients compared with MT preservation patients. No difference between the groups was noted for quality of life outcomes, nasal airway resistance, or rates of postoperative frontal sinusitis. In regard to postoperative endoscopic examinations, some studies note greater improvement in the MT resection group compared with the MT preservation group, while others were equivalent.

CONCLUSION

Although some studies show outcome benefit in MT resection patients compared with MT preservation patients, several others show no difference. When MT resection was appropriately indicated, no studies showed detrimental effects compared with MT preservation in their designated outcomes. Additional more stringent studies are warranted.

The effect of radiofrequency turbinoplasty vs two other methods in the management of polypoid changes of the middle turbinate: a randomized trial

BACKGROUND

The aim of this study was to evaluate the effectiveness of middle turbinate radiofrequency (RF) turbinoplasty for the management of the polypoid middle turbinate compared to middle turbinate resection and middle turbinate medialization.

METHODS

The study was performed on 90 patients at a tertiary referral hospital with nasal polyposis resistant to maximal medical treatment. At the time of functional endoscopic sinus surgery (FESS), patients were randomized into 3 groups with respect to the management of the middle turbinate: middle turbinate turbinoplasty by RF; partial resection of the middle turbinate; and medialization of the middle turbinate by scarification to the septum. We evaluated the patients' symptoms according to the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and 1 year after surgery. Additionally, polyp recurrence and complications were compared among the 3 groups.

RESULT

One year after surgery, there was no significant difference in SNOT-22 scores between the groups. However, the RF group had a significantly lower polyp recurrence rate when compared to other groups (p < 0.05).

CONCLUSION

RF middle turbinate turbinoplasty could be considered an alternative to other common approaches, but it needs further long-term studies before widespread usage.

Quantitative analysis of progressive removal of nasal structures during endoscopic suprasellar approach

OBJECTIVES/HYPOTHESIS

Following recent studies measuring working area and surgical freedom of transcranial approaches, we aimed to quantify the gain achieved with progressive removal of nasal structures during the endoscopic endonasal suprasellar approach.

STUDY DESIGN

Human cadaveric anatomic study.

METHODS

The width of the endoscopic endonasal corridor to the suprasellar area was obtained and measured in five cadaver heads using a computerized tracking system with six steps: 1) standard approach with monolateral lateralization of middle turbinate; 2) standard bilateral lateralization of the middle turbinates; 3) monolateral middle turbinectomy; 4) bilateral middle turbinectomy; 5) monolateral ethmoidectomy; 6) bilateral ethmoidectomy.

RESULTS

The progressive removal of nasal structures offers a nonlinear increasing of the working area during the first steps of the procedure. The maximum advantage is offered by bilateral lateralization of the middle turbinates (102.7% increase in exposure), whereas a moderate increase is observed with each following step. Surgical freedom mainly increased during the first part of the approach, that is, with a monolateral right middle turbinectomy (17.9% raise of maneuverability), whereas additional steps did not increase surgical freedom enough to justify an aggressive nasal disruption.

CONCLUSIONS

Monolateral turbinectomy on the side of endoscope docking represents the best solution, optimizing working area and surgical freedom (offering increases of 116.9% and 17.9%, respectively). Bilateral turbinectomy, together with a monolateral anterior and posterior ethmoidectomy, can be reserved for selected cases (increases of 148.5% and 24.7%, respectively). Bilateral ethmoidectomy does not significantly improve surgical freedom (0.81%).

LEVEL OF EVIDENCE

N/A. Laryngoscope 124:2231-2237, 2014.

Factors affecting time to revision sinus surgery for nasal polyps: a 25-year experience

OBJECTIVES/HYPOTHESIS

Surgical treatment for chronic rhinosinusitis with nasal polyps (CRSwNP) is often followed by polyp regrowth with return of symptoms. The purpose of this study is to identify clinical factors that influence the time interval to revision sinus surgery in patients with nasal polyps.

STUDY DESIGN

Retrospective cohort study.

METHODS

Records of 299 individuals who underwent two or more surgeries for the diagnosis of nasal polyps by the senior author (RM) from 1987 through 2011 were reviewed. The time between surgical interventions were compared to patient demographics, comorbidities, endoscopic examination, computed tomography (CT) stage, extent of surgery, and pathologic findings.

RESULTS

The mean time interval between polyp surgeries was 4.87 ± 3.61 years (range 0.7-18.6 years). The median time to revision surgery was shorter in patients who smoked compared to nonsmokers (2.82 vs. 4.31 years, respectively, P = .022) and longer in patients who underwent middle turbinate resection rather than preservation (4.56 vs. 3.93 years, respectively, P = .048). Kaplan-Meier survival analysis confirmed these findings, but the beneficial effect of turbinectomy appeared to dissipate by 8 years. Neither a history of asthma nor advanced CT stage influenced the time to revision surgery.

CONCLUSION

The time course between sinus surgeries in patients with regrowth of nasal polyps appears to be affected by certain modifiable extrinsic factors, including smoking on the part of the patient and operative technique on the part of the surgeon. The performance of middle turbinate resection during sinus surgery appears to extend the time interval until a revision procedure is required.

Meticulous endoscopic sinus surgery to prevent recurrence of massive nasal polyposis

OBJECTIVE

To evaluate the effect of meticulous endoscopic surgery, including opening of all involved sinus cells, on the subsequent symptoms and endoscopic findings of patients with massive nasal polyposis.

STUDY DESIGN AND METHOD

One hundred patients with massive nasal polyposis resistant to medical treatment were selected. We documented each patient's demographic data, associated diseases, endoscopic findings, Lund-Mackay score and Sino-Nasal Outcome Test 22 (SNOT22) symptom score. All patients were followed up for at least two years to evaluate any recurrence.

RESULTS

Of the 100 patients, 20 per cent had a history of asthma and 27 per cent had undergone previous surgery. All underwent endoscopic sinus surgery. After two years of follow up, 8 per cent had recurrence requiring surgery. Recurrence was significantly associated with a history of asthma (p < 0.001) and the histopathological presence of eosinophilia (p = 0.014).

CONCLUSION

Meticulous endoscopic opening of all involved sinus cells can be a safe and effective means of controlling massive nasal polyposis, with an acceptable recurrence rate.

Beyond the "central sinus": radiographic findings in patients undergoing revision functional endoscopic sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) is widely used by otolaryngologists to treat chronic rhinosinusitis (CRS). The sinonasal anatomy and pathology found in patients with CRS varies widely, as does the FESS technique practiced by otolaryngologists. Variations in the completeness of cell group dissection, combined with the technical challenge of angled endoscopy, result in a wide variation of the post-FESS cavities harboring persistent disease. The purpose of this study was to identify previously incompletely dissected anatomic structures associated with mucosal thickening found in patients undergoing revision FESS for persistent or recurrent CRS.

METHODS

Retrospective review of axial, coronal, and sagittal computed tomography (CT) scans of patients undergoing revision FESS by 3 fellowship-trained rhinologists at a tertiary referral center.

RESULTS

The CT scans of 55 patients undergoing revision FESS were reviewed. The most frequent radiographic findings were residual anterior and posterior ethmoid cells or septations, found in 65% of sides and 75% of patients. In addition, residual anterior ethmoid agger nasi cells, unopened sphenoid, and residual uncinates were found in 52%, 51%, and 46% of sides, respectively. A large percentage of the patients demonstrated residual ethmoid cells present on the lamina papyracea and skull base, with a lower number found posterior to the middle turbinate basal lamella. A greater number of residual right-sided vs left-sided ethmoid cells was noted, with the difference being significant (p < 0.05) at the skull base.

CONCLUSION

Analysis of CT scans of patients undergoing revision FESS for persistent or recurrent CRS frequently reveals persistent anatomical structures or incompletely resected cells associated with persistent mucosal thickening. Meticulous, complete cell group dissection combined with use of angled endoscopy along with identification of possible predisposing structures may aid in the reduction of need for revision surgery.

Rhinosinusitis and aspirin-exacerbated respiratory disease

Rhinosinusitis is a feature of aspirin-exacerbated respiratory disease (AERD), which in the initial phase is manifested as nasal congestion, mostly affecting females at the age of around 30 years on average. Subsequently, nasal inflammation progresses to chronic eosinophilic rhinosinusitis, asthma, nasal polyposis, and intolerance to aspirin and to other NSAIDs. While it has been long established that NSAIDs cause inhibition of cyclooxygenase-1 (COX-1), leading to excessive metabolism of arachidonic acid (AA) to cysteinyl-leukotrienes (cys-LTs), there is now evidence that both cytokines and staphylococcus superantigens amplify the inflammatory process exacerbating the disease. This paper gives a brief overview of the development of chronic rhinosinusitis (CRS) in sensitive patients, and we share our experience in the diagnosis and management of CRS in AERD.

Advances in the surgical management of chronic sinusitis and nasal polyps

Current research has only reinforced the belief that chronic rhinosinusitis is a multifactorial and idiosyncratic disease process. Most basic science research on the topic focuses on delineating the many proposed contributing factors and attempting to establish therapeutic targets. In patients whose symptoms do not respond to medical therapy, endoscopic sinus surgery may be offered. Several surgical techniques have been proposed, and it would appear that certain techniques are ideal for certain situations. Recent clinical research has focused on the introduction of new technology and new techniques. Additionally, investigators have looked for ways to optimize current techniques and to determine which patient populations may expect to benefit from which types of interventions.

Radiological findings in patients undergoing revision endoscopic sinus surgery: a retrospective case series study

Background

Functional endoscopic sinus surgery (FESS) is now a well-established strategy for the treatment of chronic rhinosinusitis which has not responded to medical treatment. There is a wide variation in the practice of FESS by various surgeons within the UK and in other countries.

Objectives

To identify anatomic factors that may predispose to persistent or recurrent disease in patients undergoing revision FESS.

Methods

Retrospective review of axial and coronal CT scans of patients undergoing revision FESS between January 2005 and November 2008 in a tertiary referral centre in South West of England.

Results

The CT scans of 63 patients undergoing revision FESS were reviewed. Among the patients studied, 15.9% had significant deviation of the nasal septum. Lateralised middle turbinates were present in 11.1% of the studied sides, and residual uncinate processes were identified in 57.1% of the studied sides. There were residual cells in the frontal recess in 96% of the studied sides. There were persistent other anterior and posterior ethmoidal cells in 92.1% and 96% of the studied sides respectively.

Conclusions

Analysis of CT scans of patients undergoing revision FESS shows persistent structures and non-dissected cells that may be responsible for persistence or recurrence of rhinosinusitis symptoms. Trials comparing the outcome of conservative FESS techniques with more radical sinus dissections are required.

Surgery of the turbinates and "empty nose" syndrome

Surgical therapy of the inferior and/or middle turbinate is indicated when conservative treatment options have failed. The desired goal is a reduction of the soft tissue volume of the turbinates regarding the individual anatomic findings, whilst simultaneously conserving as much mucosa as possible. As the turbinates serve as a functional entity within the nose, they ensure climatisation, humidification and cleaning of the inhaled air. Thus free nasal breathing means a decent quality of life, as well.Regarding the multitude of different surgical techniques, we confirm that no ideal standard technique for turbinate reduction has been developed so far. Moreover, there is a lack of prospective and comparable long-term studies, which makes it difficult to recommend evidence-based surgical techniques. However, the anterior turbinoplasty seems to fulfil the preconditions of limited tissue reduction and mucosa-preservation, and therefore it is the method of choice today.Radical resection of the turbinates may lead to severe functional disturbances developing a secondary atrophic rhinitis. The "empty nose" syndrome is a specific entity within the secondary atrophic rhinitis where intranasal changes in airflow result in disturbed climatisation and also interfere with pulmonary function. Results deriving from an actual in vivo study of climatisation and airflow in "empty nose" patients are presented.

Relationship between Postoperative Recurrence Rate and Eosinophil Density of Nasal Polyps

Objectives

Nasal polyps develop as a result of chronic inflammation, mostly accompanied by pronounced eosinophil leukocyte infiltration. In this study we aimed to investigate the relationship between eosinophil density in nasal polyps and the postoperative recurrence rate of this disease.

Methods

Forty-two patients who underwent endoscopic sinus surgery for massive nasal polyposis by one surgeon were included in the study. The eosinophil leukocyte densities in nasal polyps were determined retrospectively on histologic slides by use of computer-assisted image analysis software. The patients were assigned to group 1, in whom nasal polyps contained up to 3 eosinophils per 1,000 urn2, and group 2, in whom nasal polyps contained 4 or more eosinophils per 1,000 um2. The postoperative recurrence rates of nasal polyps were compared in the two groups.

Results

There were 20 patients in group 1 and 22 patients in group 2. Postoperative polyp recurrence was detected in 5 of 20 patients (25.0%) in group 1 and in 18 of 22 patients (81.8%) in group 2 during the 30-month postoperative follow-up period (p < 0.05).

Conclusions

The eosinophil density of nasal polyps can be used to get an estimate of the postoperative recurrence risk. Eosinophil-rich nasal polyps have a higher postoperative recurrence rate.

Outcomes after middle turbinate resection: revisiting a controversial topic

OBJECTIVES/HYPOTHESIS

To evaluate differences in endoscopy exam, olfactory function, and quality-of-life (QOL) status after endoscopic sinus surgery (ESS) for patients with and without bilateral middle turbinate (BMT) resection.

STUDY DESIGN

Open, prospective, multi-institutional cohort.

METHODS

Subjects completing enrollment interviews, computed tomography (CT), and endoscopy exam were asked to provide pre- and postoperative responses to the Smell Identification Test (SIT), Rhinosinusitis Disability Index (RSDI), Chronic Sinusitis Survey (CSS), and the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Bivariate and multivariate analyses were performed at the .05 alpha level.

RESULTS

Forty-seven subjects with BMT resection were compared to 195 subjects without BMT resection with a mean follow-up of 17.4 months postoperatively. Patients with BMT resection were more likely to have asthma (P = .001), aspirin intolerance (P = .022), nasal polyposis (P = .025), and prior sinus surgery (P = .002). Patients with BMT resection had significantly higher baseline disease burden measured by endoscopy, CT, and SIT scores (P < .001). No significant differences in improvement were found in RSDI, CSS, or SF-36 scores between patients with BMT resection and those with BMT preservation (P > .05). Patients undergoing BMT resection were more likely to show improvements in mean endoscopy (-4.5 +/- 5.2 vs. -1.9 +/- 4.3; P = .005) and olfaction (5.3 +/- 10.8 vs. 1.3 +/- 7.6, P = .045) compared to those with BMT preservation.

CONCLUSIONS

This investigation found no difference in QOL outcomes in patients with BMT preservation vs. resection. Patients undergoing BMT resection did, however, show greater improvements in endoscopy and SIT scores, which persisted after controlling for confounding factors.