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Novarria GA, Vultaggio F, Saginario V, Felisati G, Saibene AM. Efficacy and safety of middle turbinate surgery: a systematic review. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08825-4. [PMID: 38992192 DOI: 10.1007/s00405-024-08825-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 07/02/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE Middle turbinate (MT) surgery is extremely common during endoscopic sinus surgery procedures, though no agreement exists on which techniques provide the best outcomes. This PRISMA-compliant systematic review aims to assess which MT surgery technique yields the least postoperative adverse effects and the best objective and subjective outcomes. METHODS A comprehensive search criteria was conducted in multiple databases up to July 3, 2023, to identify studies reporting surgical treatments of the MT. After screening and quality assessment, 14 articles were included for analysis. Data on patients demographics, surgical approaches, postoperative treatment and follow-up, objective and subjective outcomes were extracted and reviewed. RESULTS Out of 173 unique papers identified, 14 articles met the inclusion criteria, predominantly randomized controlled trials (n = 9). Antero-inferior middle turbinectomy was the predominant surgical approach. Most studies evaluated results with postoperative endoscopy, a superior outcome was documented in the intervention group (ten out of eleven cases). In four out five studies using the SNOT-22, the treatment group was associated with a statistically significant improvement. Olfactory questionnaires highlighted superior olfactory outcome in two out of three studies. The UPSIT score revealed no significant difference between groups. Objective olfactory assessments favored treatment groups in both studies utilizing olfactometry. CONCLUSIONS It seems that a partial MT surgical approach consistently yields subjective and objective improvements compared to conservative measures, also suggesting a positive impact on smell function. Despite it appears that better outcomes with fewer complications are consistently achieved with partial techniques, it remains challenging identifying which partial technique surpasses the others, due to significant heterogeneity among the studies.
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Affiliation(s)
- Gabriele Alessandro Novarria
- Department of Otolaryngology and Head and Neck Surgery, Istituto Clinico Città Studi, Via Jommelli 17, Milano, 20131, Italy.
| | - Federica Vultaggio
- Department of Clinical Sciences and Community Health, San Giuseppe Hospital, Università Degli Studi di Milano, Milan, Italy
| | - Vittorio Saginario
- Department of Otolaryngology and Head and Neck Surgery, Istituto Clinico Città Studi, Via Jommelli 17, Milano, 20131, Italy
| | - Giovanni Felisati
- Department of Health Sciences, Otorhinolaryngology Unit, Santi Paolo e Carlo Hospital, University of Milan, Milan, Italy
| | - Alberto Maria Saibene
- Department of Health Sciences, Otorhinolaryngology Unit, Santi Paolo e Carlo Hospital, University of Milan, Milan, Italy
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Al-Salihi MM, Rahman M, Al-Jebur MS, Al-Salihi Y, Shihadeh O, Hammadi F, Ayyad A. Effect of preservation versus resection of turbinate on olfactory function in endoscopic trans-nasal trans-sphenoidal pituitary surgery: a systematic review and meta-analysis. Neurol Res 2024; 46:444-452. [PMID: 38467610 DOI: 10.1080/01616412.2024.2328493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Utilizing endoscopes in surgery offers advantages and concerns, including potential nasal function impacts. Hyposmia following Transseptal Transsphenoidal hypophysectomy ranges from 0% to 2.2%. Debates persist about managing the M.T. in endoscopic sinus surgery due to its impact on nasal function. While preservation is recommended for sinonasal health, debates continue, as certain cases require resection. Our meta-analysis aims to compare turbinate resection and preservation effects on olfactory function. METHODS We searched five electronic databases to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. Our continuous outcomes were pooled as standardized mean difference with 95% CI. Statistical analyses was done by RevMan. RESULTS Our meta-analysis included four studies involving 235 patients (81 males). Evaluating changes in olfaction scores, two one-month studies (82 patients) revealed no significant difference between preservation and resection groups (Std.MD = 0.05[-0.39, 0.50], p = 0.81). For three-month assessments (146 patients), SNOT tests indicated no significant difference (Std.MD = 0.21, 95% CI[-0.11, 0.54], p = 0.20). Two studies used other tests on 70 patients at three months, yielding no significant difference (Std.MD = 0.13, 95% CI [-0.35, 0.62], p = 0.59). Two six-month studies (72 patients) similarly found no significant difference (Std.MD = 0.09, 95% CI [-0.39, 0.56], p = 0.72). CONCLUSION Our meta-analysis involving 235 patients examined olfaction score changes over various time frames in trans-nasal trans-sphenoidal pituitary surgeries. No significant differences were observed between turbinate preservation and resection groups at one month, three months, or six months post-surgery.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Mohammed Rahman
- Department of Neurosurgery, St. Marys Hospital, Decatur, IL, USA
| | | | | | - Omar Shihadeh
- Department of Neurosurgery, Hamad General Hopsital, Doha, Qatar
| | - Firas Hammadi
- Department of Neurosurgery, Hamad General Hopsital, Doha, Qatar
| | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hopsital, Doha, Qatar
- Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
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Hsu PY, Hsieh LC, Wang YH, Chen SJ, Chan YK, Shen KH, Wang YP. Olfactory Outcomes After Middle Turbinate Resection in Endoscopic Transsphenoidal Surgery: A Prospective Randomized Study. Otolaryngol Head Neck Surg 2022; 167:964-970. [PMID: 35316101 DOI: 10.1177/01945998221086202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Endoscopic endonasal transsphenoidal surgery is safe and effective for sellar and parasellar tumor removal. Partial middle turbinate (MT) resection is sometimes performed to optimize the surgical field and facilitate postoperative care. Disturbances in olfaction are concerning because of the lack of randomized studies in this field. STUDY DESIGN Prospective randomized trial. SETTING Single academic medical center. METHODS We resected the lower halves of bilateral MTs in the resected group and laterally fractured bilateral MTs in the preserved group. Olfactory outcomes and sinonasal conditions were assessed by using the validated Taiwan Smell Identification Test and Lund-Kennedy Endoscopy Score, respectively. Forty-nine patients were enrolled in the final analysis, of whom 23 underwent partial MT resection. RESULTS The average Taiwan Smell Identification Test result was 36.9 one month after surgery, with a significant change of -4.4 ± 3.1 (mean ± SD; P < .01) from baseline. The impact was not significant at 3 months (-2.1 ± 2.6, P = .13) or 6 months (0.3 ± 2.0, P = .79). Between the MT resection and preservation groups, there were no significant differences at postoperative 1 month (P = .60), 3 months (P = .86), and 6 months (P > .99). Lund-Kennedy Endoscopy Score was still higher at 3 months (P = .006) after surgery but returned to the preoperative level at 6 months (P = .63). CONCLUSIONS Endoscopic endonasal transsphenoidal surgery may affect olfaction at 1 month after surgery, and olfactory function is expected to return after 3 months. Partial MT resection did not result in additional olfactory loss. It is safe to perform partial MT resection during surgery without compromising the olfactory outcomes.
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Affiliation(s)
- Pei-Yuan Hsu
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei
| | - Li-Chun Hsieh
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei.,School of Medicine, Mackay Medical College, New Taipei City.,Department of Audiology and Speech Language Pathology, Mackay Medical College, New Taipei City
| | - Yu-Hsuan Wang
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei
| | - Shiu-Jau Chen
- School of Medicine, Mackay Medical College, New Taipei City.,Department of Neurosurgery, Mackay Memorial Hospital, Taipei
| | - Yun-Kai Chan
- Department of Neurosurgery, Mackay Memorial Hospital, Taipei
| | - Kuang-Hsuan Shen
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei
| | - Ying-Piao Wang
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei.,School of Medicine, Mackay Medical College, New Taipei City.,Department of Audiology and Speech Language Pathology, Mackay Medical College, New Taipei City
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Pinheiro-Neto C, Rowan NR, Celda MP, Mukherjee D, Gompel JJV, Choby G. Optimizing Quality of Life and Minimizing Morbidity through Nasal Preservation in Endoscopic Skull Base Surgery: A Contemporary Review. J Neurol Surg B Skull Base 2022; 83:602-610. [PMID: 36393878 PMCID: PMC9653292 DOI: 10.1055/s-0042-1749654] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/21/2022] [Indexed: 10/15/2022] Open
Abstract
Introduction Endoscopic endonasal approaches (EEAs) are increasingly utilized for intracranial pathology. As opposed to sinonasal tumors, the nasal cavity is being used as a corridor to access these intracranial tumors but is not the site of primary surgical intent. Accordingly, there has been recent interest in preserving intranasal structures not directly involved by tumor and improving postoperative sinonasal quality of life (QOL). Objectives The aim of the study is to highlight recent advances in EEA techniques focused on improving sinonasal QOL including turbinate preservation, reducing the morbidity of reconstructive techniques, and the development of alternative minimally invasive EEA corridors. Methods The method of the study involves contemporary literature review and summary of implications for clinical practice. Results Nasoseptal flap (NSF) harvest is associated with significant morbidity including septal perforation, prolonged nasal crusting, and external nasal deformities. Various grafting and local rotational flaps have demonstrated the ability to significantly limit donor site morbidity. Free mucosal grafts have re-emerged as a reliable reconstructive option for sellar defects with an excellent sinonasal morbidity profile. Middle turbinate preservation is achievable in most EEA cases and has not been shown to cause postoperative obstructive sinusitis. Recently developed minimally invasive EEA techniques such as the superior ethmoidal approach have been described to better preserve intranasal structures while allowing intracranial access to resect skull base tumors and have shown promising sinonasal QOL results. Conclusion This contemporary review discusses balancing effective skull base reconstructive techniques with associated morbidity, the role of turbinate preservation in EEA, and the development of unique EEA techniques that allow for increased nasal structure preservation.
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Affiliation(s)
- Carlos Pinheiro-Neto
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Nicholas R. Rowan
- Department of Otolaryngology—Head & Neck Surgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Maria Peris Celda
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Debraj Mukherjee
- Department of Neurologic Surgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Jamie J. Van Gompel
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Garret Choby
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
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5
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Anchan SV, Shah V, Jalisatgi RR, Naik AS, Sidappa R, Pandurangi AS. A Comparative Study of Interventions of Middle Turbinate Medialization in Endoscopic Sinus Surgery. Indian J Otolaryngol Head Neck Surg 2022; 74:1706-1712. [PMID: 36452729 PMCID: PMC9701921 DOI: 10.1007/s12070-021-02861-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022] Open
Abstract
The shape and position of middle turbinate play an important role in ventilation and drainage of the osteomeatal complex. The preservation of middle turbinate is one of the major goals of functional endoscopic sinus surgery (FESS). Middle turbinate intervention is essential to prevent obliteration of osteomeatal complex. The aim of this prospective study is to postulate which middle turbinate intervention is most effective and compare the results with conventional technique. In this randomized controlled study, 60 patients were included of the age group of 15-60 years who presented to the Otorhinolaryngology OPD of our institute between November 2017 to June 2019 with symptoms of chronic sinusitis with clinical and radiological evidence and who underwent FESS. The patients were divided into three group, Group A-Bolgerization (n = 20), Group B-Vicryl-conchopexy (n = 20) and Group C-No intervention, Control group (n = 20). The patency of middle meatus and the status of middle turbinate (medialized or lateralized or neither of the two) was ascertained postoperatively. Improvement in symptoms was also evaluated. The middle turbinate was medialized in 90% of Group A and 95% of Group B cases. The middle turbinate was neither medialized nor lateralized in 70% of patients in Group C. 70% of the patients in Group A and 80% of patients in Group B had complete improvement in symptoms with no recurrence of sinusitis compared to Group C in which only 50% of the patients had improvement in symptoms due to development of synechiae. Medialization of the middle turbinate should be considered as one of the essential steps of FESS as it helps in improving the surgical outcome.
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Affiliation(s)
- Shibani Vittal Anchan
- Department of ENT, SDM College of Medical Sciences and Hospital, Affiliated to SDM University, Dharwad, Karnataka India
| | - Vidit Shah
- Department of ENT, SDM College of Medical Sciences and Hospital, Affiliated to SDM University, Dharwad, Karnataka India
| | - Roshan Ramchandra Jalisatgi
- Department of ENT, SDM College of Medical Sciences and Hospital, Affiliated to SDM University, Dharwad, Karnataka India
| | - Ashok Shekappa Naik
- Department of ENT, SDM College of Medical Sciences and Hospital, Affiliated to SDM University, Dharwad, Karnataka India
| | - Rashmi Sidappa
- Department of ENT, SDM College of Medical Sciences and Hospital, Affiliated to SDM University, Dharwad, Karnataka India
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Low CM, Vigo V, Nunez M, Fernández-Miranda JC, Patel ZM. Anatomic Considerations in Endoscopic Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:223-232. [DOI: 10.1016/j.otc.2021.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tooley AA, Kim M, Tran AQ, Kazim M, Gudis DA. Adjunctive Middle Turbinectomy for Endoscopic Medial Orbital Wall – Thyroid Eye Disease Decompression. Int Arch Otorhinolaryngol 2022; 26:e579-e584. [DOI: 10.1055/s-0041-1740156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/07/2021] [Indexed: 10/19/2022] Open
Abstract
Abstract
Introduction Middle turbinate resection (MTR) is commonly performed during endonasal endoscopic sinus and skull base surgery.
Objective The purpose of this study was to characterize the additional orbital soft-tissue volume expansion during endoscopic medial orbital wall decompression with adjunctive MTR.
Methods A retrospective review of patients who underwent endoscopic medial wall decompression with MTR was performed. The imaging software AW (GE Healthcare, Chicago, IL, USA) was used to overlay pre and postoperative orbital computed tomography (CT) images to visualize the preoperative position of the middle turbinate and the postoperative orbital soft tissue in the ethmoid bed. The imaging software Vitrea (Vital Images Inc., Minnetonka, MN, USA) was used to manually segment postoperative scans to determine the volume of orbital tissue which had filled the space previously occupied by the middle turbinate or medial to it.
Results Nine orbits from 5 patients were included in this study; all patients were female with a history of hyperthyroidism. The average age was 55.6 years (range 32–74). Of the 9 orbits, 7 (78%) had orbital soft tissue within the space of the resected middle turbinate postoperatively. The average volume of orbital tissue within or medial to this space was 0.83 +/− 0.67 cc. No patients had any postoperative complications.
Conclusions In this patient cohort, adjunctive middle turbinate resection for endoscopic medial orbital wall decompression added ∼ 0.83 cc of volume for orbital soft tissue after medial wall decompression. Middle turbinate resection is a useful adjunct to the orbital surgeon's armamentarium to augment the results of a medial orbital decompression for select patients.
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Affiliation(s)
- Andrea A. Tooley
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Kim
- Department of Otolaryngology – Head and Neck Surgery, Division of Rhinology and Anterior Skull Base Surgery, New York-Presbyterian Hospital, New York, New York
| | - Ann Q. Tran
- Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York
| | - Michael Kazim
- Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York
| | - David A. Gudis
- Department of Otolaryngology – Head and Neck Surgery, Division of Rhinology and Anterior Skull Base Surgery, New York-Presbyterian Hospital, New York, New York
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8
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Tang DM, Roxbury CR. Management of the middle turbinate during and after sinus surgery. Curr Opin Otolaryngol Head Neck Surg 2022; 30:40-45. [PMID: 34889849 DOI: 10.1097/moo.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW 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. RECENT FINDINGS 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. SUMMARY 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.
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Affiliation(s)
- Dennis M Tang
- Division of Otolaryngology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christopher R Roxbury
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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Kanjanawasee D, Campbell RG, Rimmer J, Alvarado R, Kanjanaumporn J, Snidvongs K, Kalish L, Harvey RJ, Sacks R. Empty Nose Syndrome Pathophysiology: A Systematic Review. Otolaryngol Head Neck Surg 2021; 167:434-451. [PMID: 34665687 DOI: 10.1177/01945998211052919] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The pathophysiology of empty nose syndrome (ENS) remains unclear despite significant research. The pathophysiologic mechanism of ENS was systematically reviewed. DATA SOURCES MEDLINE and Embase. REVIEW METHODS Data were systematically reviewed for studies that provided original data on pathophysiology. RESULTS A total of 2476 studies were screened, and 19 met the inclusion criteria: 13 case-control and 6 cross-sectional. Nine pathophysiologic themes were identified.• Demographics: ENS symptoms had no relationship with climatic factors.• Symptomatology: ENS patients demonstrated high symptom severity.• Mental health: Anxiety and depression including hyperventilation were reported in >50% of ENS patients and correlated with ENS symptom severity.• Anatomic features: Structural changes in response to turbinate surgery were similar between ENS and non-ENS patients.• Airflow analysis: Airflow parameters were similar between ENS and non-ENS patients after turbinate surgery. On computational fluid dynamic analysis, differences were found on multiple outcomes.• Diagnostic testing: The menthol detection test was impaired in ENS, and cotton placement in the airway improved ENS symptoms.• Cognitive function: Functional magnetic resonance imaging showed activation in emotional processing area during breathing.• Olfactory function: Subjective impairment was reported in ENS, but quantitative measures were similar to non-ENS patients.• Mucosal physiology/innate immunity: Turbinate histopathology in ENS showed a tissue-remodeling pattern. Nasal nitric oxide level was lower in ENS patients. CONCLUSION There is evidence of high comorbid mental health disorders in ENS patients. An abnormal trigeminal-thermoreceptor response may be present in some patients. The influence of altered airflow and the evidence of surgery as the cause for ENS are unclear.
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Affiliation(s)
- Dichapong Kanjanawasee
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Raewyn G Campbell
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Otorhinolaryngology-Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Janet Rimmer
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia.,Woolcock Institute, University of Sydney, Sydney, Australia.,Faculty of Medicine, Notre Dame University, Sydney, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Jesada Kanjanaumporn
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Larry Kalish
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Concord General Hospital, University of Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Richard J Harvey
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Raymond Sacks
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Concord General Hospital, University of Sydney, Australia
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İsmi O, Meşe F, Gür H, Gürses İ, Vayısoğlu Y, Görür K, Özcan C. Olfactory neuroepithelium in the middle turbinate: is there any impact on olfaction function after lateral marsupialization for concha bullosa surgery? Braz J Otorhinolaryngol 2021; 88 Suppl 5:S12-S18. [PMID: 34348856 PMCID: PMC9800953 DOI: 10.1016/j.bjorl.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/08/2021] [Accepted: 06/20/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The effect of the quantity of olfactory neuroepithelium in the middle turbinate on the postoperative olfactory function for middle turbinate concha bullosa patients has not yet been evaluated. OBJECTIVE The primary aim of this study was to investigate the olfactory structures in the middle turbinate by immunohistochemical analysis of the olfactory marker protein and to correlate the immunostaining results with the olfaction test results for patients with middle turbinate concha bullosa. METHODS Surgical materials of 18 middle turbinate concha bullosa patients who had undergone lateral marsupialization surgery were immunostained with olfactory marker protein antibodies. Smell diskettes olfaction test was applied to all of the study group patients both preoperatively and three months postoperatively. A visual analog scale was used to quantify the sense of nasal obstruction. RESULTS It was observed that the postoperative smell scores and the nasal obstruction visual analog scale values were significantly improved as compared to the preoperative values (p < 0.05). In addition, there was a significant correlation between the smell score gain and the visual analog scale gain values (r = 0.682). Results also indicated no significant correlation between the olfactory marker protein staining scores and the smell scores (p > 0.05). CONCLUSION This first paper demonstrated that the quantity of the olfactory mucosa in the middle turbinate was not a determining factor for the postoperative smell function degree for middle turbinate concha bullosa patients. The underlying cause of the olfactory deficit for middle turbinate concha bullosa patients seems to be obstruction related rather than the middle turbinate's olfactory mucosa containing status.
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Affiliation(s)
- Onur İsmi
- University of Mersin, Faculty of Medicine, Department of Otorhinolaryngology, Mersin, Turkey,Corresponding author.
| | - Feyzi Meşe
- Special Batman Dünya Hospital, Otorhinolaryngology specialist, Batman, Turkey
| | - Harun Gür
- University of Mersin, Faculty of Medicine, Department of Otorhinolaryngology, Mersin, Turkey
| | - İclal Gürses
- University of İstanbul, Cerrahpaşa Faculty of Medicine, Department of Pathology, İstanbul, Turkey
| | - Yusuf Vayısoğlu
- University of Mersin, Faculty of Medicine, Department of Otorhinolaryngology, Mersin, Turkey
| | - Kemal Görür
- University of Mersin, Faculty of Medicine, Department of Otorhinolaryngology, Mersin, Turkey
| | - Cengiz Özcan
- University of Mersin, Faculty of Medicine, Department of Otorhinolaryngology, Mersin, Turkey
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11
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Law RH, Ahmed AM, Van Harn M, Craig JR. Middle turbinate resection is unlikely to cause empty nose syndrome in first year postoperatively. Am J Otolaryngol 2021; 42:102931. [PMID: 33550027 DOI: 10.1016/j.amjoto.2021.102931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Richard H Law
- Department of Otolaryngology Head and Neck Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202, USA
| | - Abdelwahab M Ahmed
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA
| | - Meredith Van Harn
- Department of Public Health Sciences, Henry Ford Health System, 1 Ford Place, Detroit, MI 48202, USA
| | - John R Craig
- Department of Otolaryngology Head and Neck Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202, USA.
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 390] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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Issa K, Teitelbaum JI, Jang DW, Goldstein BJ, Chan L, Hachem RA. Sinus Irrigation Penetration After Proposed Modified Draf IIa Technique in a Side-to-Side Cadaveric Model. Am J Rhinol Allergy 2020; 35:487-493. [PMID: 33086859 DOI: 10.1177/1945892420969141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endoscopic sinus surgery (ESS) is an effective intervention for patients with medically refractory chronic rhinosinusitis. Frontal sinusotomy is the most challenging part of ESS, with one of the key outcomes being access for topical irrigations. OBJECTIVE The purpose of this study is to compare irrigation penetration into the frontal sinus following Draf IIa versus modified Draf IIa frontal sinusotomy. METHODS Four fresh cadaver heads were used in this experiment. Draf IIa was performed on one side of each head and a modified Draf IIa on the contralateral side. This proposed modification consists of a Draf IIa combined with an agger nasi punch-out procedure and partial trimming of the vertical lamella of the middle turbinate back to the posterior table of the frontal sinus without drilling the beak. Each head was irrigated with methylene blue-dyed water and recorded by rigid endoscopy through an endonasal view (EV) of the frontal sinus and frontal trephination view (TV). Two blinded rhinologists scored the extent of staining (using an ordinal scale of 0 to 3) for each side. A case report where the modified Draf IIa was performed is also described. RESULTS After modified Draf IIa sinuosotomy, the mean score for the EV was 2.125 and for the TV was 2, versus 0.875 and 0.625 for traditional Draf IIa, respectively. There was a statistically significant increase for both EV (p = 0.019) and TV (p = 0.018) after modified Draf IIa. CONCLUSION In our cadaveric model, this procedural modification improved penetration of postoperative irrigations into the frontal sinus. This simple technique may be easily adapted into frontal ESS when indicated.
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Affiliation(s)
| | - Jordan I Teitelbaum
- Division of Rhinology & Endoscopic Skull Base Surgery, Department of Head and Neck Surgery & Communications Sciences, Duke University Medical Center, Durham, North Carolina
| | - David W Jang
- Division of Rhinology & Endoscopic Skull Base Surgery, Department of Head and Neck Surgery & Communications Sciences, Duke University Medical Center, Durham, North Carolina
| | - Bradley J Goldstein
- Division of Rhinology & Endoscopic Skull Base Surgery, Department of Head and Neck Surgery & Communications Sciences, Duke University Medical Center, Durham, North Carolina
| | - Lyndon Chan
- Division of Rhinology & Endoscopic Skull Base Surgery, Department of Head and Neck Surgery & Communications Sciences, Duke University Medical Center, Durham, North Carolina
| | - Ralph Abi Hachem
- Division of Rhinology & Endoscopic Skull Base Surgery, Department of Head and Neck Surgery & Communications Sciences, Duke University Medical Center, Durham, North Carolina
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Chou CT, Valappil B, Mattos JL, Snyderman CH, Gardner PA, Fernandez-Miranda JC, Wang EW. The Effect of Nasoseptal Flap Elevation on Post-Operative Olfaction and Sinonasal Quality of Life: A Prospective Double-Blinded Randomized Controlled Trial. Am J Rhinol Allergy 2020; 35:353-360. [PMID: 32921136 DOI: 10.1177/1945892420957505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of nasoseptal flaps (NSF) for defect reconstruction in endoscopic endonasal approaches (EEA) to cranial base pathology has markedly reduced rates of cerebrospinal fluid leak. However, the effect of NSF use on post-operative olfaction remains unclear. OBJECTIVE To evaluate the impact of NSF use during EEA on binarial and uninarial olfaction, and sinonasal quality of life (QOL). METHODS This was a prospective double-blinded randomized controlled trial. Patients undergoing EEA for sellar pathology were recruited from the University of Pittsburgh Medical Center from December 2014 to May 2017. Subjects were randomized pre-operatively to a side of NSF harvest. Olfaction and QOL were assessed pre-operatively and 6 to 12 months post-operatively using the University of Pennsylvania Smell Identification Test, "Sniffin' Sticks," and Sinonasal Outcomes Test 22. The side of dominant uninarial olfaction was determined using "Sniffin' Sticks." RESULTS Thirty-one patients were enrolled. Sixteen underwent EEA without NSF (control group) and 15 with NSF. A dominant side of olfaction was identified in 14 patients with NSF; 8 patients were randomized to NSF harvest on the dominant side and the remaining 6 on the non-dominant side. NSF elevation resulted in a 4% decrease in University of Pennsylvania Smell Identification Test scores, but was not statistically significant compared to controls. Similarly, NSF elevation on the side of dominant olfaction resulted in a 6% decrease, but was not statistically significant when compared to the non-dominant elevation group. Change in rhinologic QOL as determined by the Sinonasal Outcomes Test 22 was not significantly different between any of the groups. CONCLUSIONS The use of NSF during EEA for sellar pathology does not have a significant effect on olfaction or rhinologic QOL. The presence of a dominant side of olfaction is not a primary consideration when deciding the side of NSF harvest.
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Affiliation(s)
- Courtney T Chou
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Benita Valappil
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jose L Mattos
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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15
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Two different therapies for the middle turbinate during endoscopic sinus surgery for chronic rhinosinusitis. Eur Arch Otorhinolaryngol 2020; 277:3079-3089. [DOI: 10.1007/s00405-020-06184-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
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16
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Pinther S, Deeb R, Peterson EL, Standring RT, Craig JR. Complications Are Rare From Middle Turbinate Resection: A Prospective Case Series. Am J Rhinol Allergy 2019; 33:657-664. [DOI: 10.1177/1945892419860299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Steven Pinther
- Department of Otolaryngology, Ascension Health, Detroit, Michigan
| | - Robert Deeb
- Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
| | - Edward L. Peterson
- Department of Public Health Services, Henry Ford Health System, Detroit, Michigan
| | | | - John R. Craig
- Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
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17
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Luk LJ, Ikeda A, Wise SK, DelGaudio JM. Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair. Otolaryngol Head Neck Surg 2019; 161:522-528. [PMID: 31039072 DOI: 10.1177/0194599819847944] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects. STUDY DESIGN A retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years. SETTING Tertiary care rhinology practice. SUBJECTS Adult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic). METHODS Patients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate. RESULTS Of 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed (P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%. CONCLUSIONS We present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.
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Affiliation(s)
- Lauren J Luk
- 1 Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California, USA
| | - Allison Ikeda
- 2 Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Sarah K Wise
- 2 Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - John M DelGaudio
- 2 Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
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18
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Kim SW, Kim RB, Kang H, Cho HJ, Joo YH, Jeon YJ, Jeon SY. Influence of a medialized middle turbinate on olfactory function: a prospective randomized double-blind study. Int Forum Allergy Rhinol 2019; 9:473-478. [PMID: 30609310 DOI: 10.1002/alr.22279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 11/29/2018] [Accepted: 12/16/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Medialization of the middle turbinate (MT) is an effective technique to prevent recurrent rhinosinusitis but could, in theory, reduce olfactory function by interfering the odorants to reach the olfactory mucosae. We performed a prospective randomized double-blind trial under the hypothesis that olfactory functions would be affected by the status of olfactory mucosae, not by MT medialization. METHODS In randomly selected sides, the unilateral MT was medialized in 80 patients undergoing bilateral endoscopic sinus surgery for chronic rhinosinusitis. The status of the bilateral olfactory cleft (OC) was photodocumented intraoperatively and categorized into patent (normal or mucosal swelling with discharge) and congested (hypertrophied mucosae or nasal polyps) groups. The butanol threshold test (BTT) was conducted in each nostril before and 6 months after the surgery. Correlation between the BTT scores and MT medialization or the OC status was assessed. No smell identification test was conducted side by side, which might limit clinical implications. RESULTS In total, 46 of 80 patients completed the trial. MT medialization was performed on the left and right side of the nose in 19 and 27 cases, respectively. The intraoperative OC status did not differ between the 2 sides. Perioperative changes in the BTT scores were similar between the medialized and intact MT sides, whereas the preoperative and postoperative BTT scores were higher in the patent OC group than in the congested OC group, regardless of side. CONCLUSION MT medialization does not impair olfactory function, and OC status is closely related to olfactory function.
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Affiliation(s)
- Sang-Wook Kim
- Department of Otorhinolaryngology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Rock Bum Kim
- Regional Cardiocerebrovascular Disease Center, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Hyunmo Kang
- Department of Otorhinolaryngology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Hyun-Jin Cho
- Department of Otorhinolaryngology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Yeon-Hee Joo
- Department of Otorhinolaryngology, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Yung Jin Jeon
- Department of Otorhinolaryngology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Sea-Yuong Jeon
- Department of Otorhinolaryngology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
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Alam S, Li C, Bradburn KH, Zhao K, Lee TS. Impact of Middle Turbinectomy on Airflow to the Olfactory Cleft: A Computational Fluid Dynamics Study. Am J Rhinol Allergy 2018; 33:263-268. [PMID: 30543120 DOI: 10.1177/1945892418816841] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND 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. OBJECTIVE To evaluate the functional impact of MTR on nasal airflow, resistance, and olfaction. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Suhyla Alam
- 1 Department of Otolaryngology - Head and Neck Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Chengyu Li
- 2 Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio.,3 Department of Mechanical Engineering, Villanova University, Villanova, Pennsylvania
| | | | - Kai Zhao
- 2 Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio.,5 Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio
| | - Thomas S Lee
- 1 Department of Otolaryngology - Head and Neck Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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Functional Endoscopic Sinus Surgery of Nasal Polyposis: The Vexing Question of Whether to Resect or Preserve Middle Turbinate. Indian J Otolaryngol Head Neck Surg 2018; 71:2025-2030. [PMID: 31763287 DOI: 10.1007/s12070-018-1450-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022] Open
Abstract
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.
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Daramola OO, Chandra RK. Chronic rhinosinusitis and endoscopic sinus surgery. World J Otorhinolaryngol Head Neck Surg 2018; 4:29-32. [PMID: 30035258 PMCID: PMC6051306 DOI: 10.1016/j.wjorl.2018.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/07/2018] [Indexed: 11/30/2022] Open
Abstract
Olfactory dysfunction is a major symptom reported by patients with chronic rhinosinusitis (CRS). Surgical treatment of this disease requires close surveillance of such dysfunction because of wide ranging implications for safety, quality of life, and impact on the flavor of foods and beverages. This review highlights key findings regarding the influences of endoscopic sinus surgery (ESS) on olfactory function across the unique presentations of CRS. Such findings provide information useful for informing patients of potential complications and for obtaining informed consent prior to surgical intervention. ESS has been shown to improve olfaction across all types of CRS as assessed through quantitative testing and subjective reports. The presence of nasal polyposis (NP) and eosinophilia have been identified as predictors of significant postoperative olfactory improvement. When indicated, judicious partial resection of the middle turbinate may result in improved olfactory function without a risk of long term complication. Careful attention to the olfactory cleft and frontal sinus recess are important in limiting olfactory complications by avoiding indiscriminate disruption of olfactory epithelium. Given the chronic nature of the disease, surveillance of olfactory function in patients with CRS is a lifelong activity that will evolve as emerging technologies become available.
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Affiliation(s)
- Opeyemi O Daramola
- Rhinology, Sinus and Skull Base Surgery, Division of Otolaryngology-Head and Neck Surgery, Crystal Run Healthcare, 2 Centerock Rd, West Nyack, NY 10994, USA
| | - Rakesh K Chandra
- Rhinology, Sinus & Skull Base Surgery, Vanderbilt University, 1215 21st Ave S, #7209 MCE S Tower, Nashville, TN 37232-8605, USA
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22
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Willson TJ, Rowan NR, Wang EW. Middle turbinate manipulation and postoperative sinus obstruction after endoscopic endonasal skull-base surgery. Int Forum Allergy Rhinol 2018; 8:1132-1135. [PMID: 29917327 DOI: 10.1002/alr.22151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 05/03/2018] [Accepted: 05/08/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Inadvertent lateralization of the middle turbinate (MT) after endoscopic sinus surgery (ESS) is cited as a common complication that results in both outflow tract obstruction and recurrent symptoms. In endoscopic endonasal skull-base surgery, the MT is frequently lateralized during the parasagittal approach. Little is known about whether this strategy has unintended consequences on the adjacent paranasal sinuses. Intentional lateralization vs surgical resection of the MT were compared for radiographic evidence of sinus obstruction in this patient population. METHODS A retrospective evaluation was conducted of pre- and postoperative Lund-MacKay (LM) scores in patients who underwent an endoscopic endonasal approach (EEA) for resection of a pituitary tumor or craniopharyngioma (transsellar or suprasellar approach) between 2012 and 2014. Side-specific LM scores were calculated at 0-3 months, 3-6 months, and >6 months. MT lateralization vs resection sides were compared. RESULTS Of the cases reviewed, 122 met the inclusion criteria. There were no statistically significant differences in LM scores of the adjacent paranasal sinuses between resected MTs as compared with surgically lateralized MTs at 3-6 months or >6 months (p = 0.551) postoperatively. Time-point of assessment was statistically significant with regard to the outcome of LM = 0 (p < 0.001), with earlier postoperative imaging correlating with higher LM scores. CONCLUSION Unlike after ESS, MT lateralization does not appear to be correlated with higher LM scores after EEA. Postoperative radiographic sinus outflow obstruction was similar in patients at all measured intervals despite differences in technical management of the MT.
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Affiliation(s)
- Thomas J Willson
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA.,Department of Otolaryngology, San Antonio Military Medical Center, San Antonio, TX.,Department of Surgery, Uniformed Services University, Bethesda, MD
| | - Nicholas R Rowan
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA
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23
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Bulla Down Endoscopic Sphenoidotomy. J Craniofac Surg 2018; 28:e785-e786. [PMID: 28938328 DOI: 10.1097/scs.0000000000004005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Surgical approach to the sphenoid sinus is still one of the most challenging steps in sinus surgery. The author describes a novel, simple, and safe technique to access sphenoid sinus to manage isolated sphenoid pathologies or approach skull base by removing the bulla ethmoidalis and temporarily lateralizing the middle turbinate during endoscopic sinus surgery. The current approach provides an effective method to access the sphenoid sinus without increasing morbidity and avoids unnecessary possible complications associated with turbinates' resection.
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Tan NCW, Goggin R, Psaltis AJ, Wormald PJ. 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. Int Forum Allergy Rhinol 2018; 8:959-963. [PMID: 29633570 DOI: 10.1002/alr.22127] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Neil C-W Tan
- Department of Surgery-Otolaryngology, University of Adelaide, Adelaide, Australia
| | - Rachel Goggin
- Department of Surgery-Otolaryngology, University of Adelaide, Adelaide, Australia
| | - Alkis J Psaltis
- Department of Surgery-Otolaryngology, University of Adelaide, Adelaide, Australia
| | - Peter-John Wormald
- Department of Surgery-Otolaryngology, University of Adelaide, Adelaide, Australia
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Manji J, Habib ARR, Amanian AA, Alsaleh S, Thamboo A, Javer AR. Potential risk factors associated with the development of synechiae following functional endoscopic sinus surgery. Eur Arch Otorhinolaryngol 2018; 275:1175-1181. [PMID: 29546557 DOI: 10.1007/s00405-018-4936-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/13/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE Synechiae formation in the middle meatus is the most common complication of functional endoscopic sinus surgery (FESS). Our objectives were to determine the incidence of synechiae occurring in a cohort of patients that have undergone FESS and identify characteristics associated with the development of synechiae postoperatively. METHODS A retrospective chart review was conducted of CRS patients, with or without nasal polyposis, that had undergone bilateral FESS in the past. All patients had received non-absorbable spacers intraoperatively that were left in situ for 6 days. Demographic and preoperative variables were analyzed to identify synechiae risk factors. A multivariable logistic regression model was constructed to estimate the probability of developing synechiae, given demographic and preoperative variables. RESULTS Two hundred cases of bilateral FESS were retrospectively reviewed. Thirty-eight (19.0%, 95% CI 13.6-24.4%) patients developed synechiae. Individuals receiving primary FESS and nasal septal reconstruction (NSR) were strongly associated with the development of synechiae (OR 3.5, 95% CI 1.5-8.5; OR 3.0, 95% CI 1.3-6.9). A multivariable logistic regression model adjusting for NSR, recurrent FESS, concha bullosa, requirement of anterior and posterior ethmoidectomy, Lund-Mackay CT score and gender, identified the likelihood of developing synechiae with a sensitivity of 68%, specificity of 73%, positive predictive value of 38% and likelihood ratio of 2.5. CONCLUSION Patients undergoing primary FESS and NSR are at greatest odds of developing postoperative synechiae. Methods of assessing risk factors and preventing synechiae formation in this population should be evaluated in future prospective investigations.
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Affiliation(s)
- Jamil Manji
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada.
| | - Al-Rahim R Habib
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Ameen A Amanian
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Saad Alsaleh
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada.,Otolaryngology - Head & Neck Surgery Department, King Abdulaziz University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Andrew Thamboo
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Amin R Javer
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
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Ye MK. The Predictive Factors of Olfactory Changes after Endoscopic Sinus Surgery. JOURNAL OF RHINOLOGY 2018. [DOI: 10.18787/jr.2018.25.2.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Mi Kyung Ye
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Catholic University of Daegu, Daegu, Korea
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Julkunen A, Terna E, Numminen J, Markkola A, Dastidar P, Karjalainen M, Huhtala H, Rautiainen M, Meurman J, Toppila-Salmi S. Inter-observer agreement of paranasal sinus computed tomography scans. Acta Otolaryngol 2017; 137:611-617. [PMID: 27981879 DOI: 10.1080/00016489.2016.1262552] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION The study demonstrated considerable inter-observer variation in certain surgically important structures. This would indicate the significance for consultation when evaluating sinus CT scans of CRS patients for planned advanced sinus surgery. OBJECTIVES After the failure of medical treatment of chronic rhinosinusitis (CRS), the need for surgery and the pre-operative planning of safe surgery is based on computed tomography (CT) findings. The aim of this prospective study was to compare inter-observer agreement of anatomical and surgical structures of sinus CT scans. The hypothesis was that the agreement between observers is good. METHODS Of these 57 CRS patients, Lund-Mackay (LM) scores and 43 other structural parameters were analyzed blinded. The reproducibility of the findings between three observers, a radiologist, an Ear, nose and throat (ENT) surgeon, and an ENT resident, were compared. RESULTS In general, there was moderate inter-observer agreement of the structures by Cohen's kappa coefficient. Poor reproducibility was observed in the following structures: optic nerve, insertion of the uncinated process, anterior ethmoidal artery, and Keros class.
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Affiliation(s)
- Anna Julkunen
- Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Emma Terna
- Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland
| | - Jura Numminen
- Department of Otorhinolaryngology, University of Tampere, Tampere, Finland
- Department of Ear and Oral diseases, Tampere University Hospital, Tampere, Finland
| | - Antti Markkola
- University of Helsinki and HUS Imaging, Helsinki, Finland
| | - Prasun Dastidar
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Finland
| | - Matti Karjalainen
- Department of Otorhinolaryngology, University of Tampere, Tampere, Finland
| | - Heini Huhtala
- School of Public Health, University of Tampere, Tampere, Finland
| | - Markus Rautiainen
- Department of Otorhinolaryngology, University of Tampere, Tampere, Finland
- Department of Ear and Oral diseases, Tampere University Hospital, Tampere, Finland
| | - Jukka Meurman
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Transplantation Laboratory, Haartman Institute, University of Helsinki, Helsinki, Finland
- Department of Allergy, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Scangas GA, Remenschneider AK, Bleier BS, Holbrook EH, Gray ST, Metson RB. Does the Timing of Middle Turbinate Resection Influence Quality-of-Life Outcomes for Patients with Chronic Rhinosinusitis? Otolaryngol Head Neck Surg 2017; 157:874-879. [DOI: 10.1177/0194599817706929] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- George A. Scangas
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Aaron K. Remenschneider
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Benjamin S. Bleier
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Eric H. Holbrook
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Stacey T. Gray
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Ralph B. Metson
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Sowerby LJ, Mann S, Starreveld Y, Kotylak T, Mechor B, Wright ED. A comparison of radiographic evidence of frontal sinusitis in middle-turbinate sacrificing versus middle-turbinate sparing approaches to the sella. Am J Rhinol Allergy 2017; 30:306-9. [PMID: 27456601 DOI: 10.2500/ajra.2016.30.4326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Initial descriptions of endoscopic approaches to the sella and pituitary involved resecting the middle turbinate (MT) to help improve access and visualization. Modifications of these procedures to preserve the MT have since been described, one rationale being to reduce the incidence of frontal sinusitis. The objective of this study was to establish the incidence of postoperative frontal sinusitis in MT sparing (MTsp) and MT sacrificing (MTsc) approaches to the sella. OBJECTIVE A retrospective cohort study that compared radiographic evidence of frontal rhinosinusitis or frontal recess obstruction after skull base surgery in patients who underwent MTsc and MTsp endonasal approaches to the sella. METHODS Consecutive retrospective review of pre- and postoperative magnetic resonance imaging from two institutions in geographic proximity but with different approaches to the sella. Mucosal thickening in the frontal sinus was measured and graded by a radiologist blinded to patient cohorts. RESULTS Seventy-five patients, based on sample size calculations, were included at each site. Baseline demographics and indications for surgery were not significantly different between the groups. No difference was seen between the groups in the overall grade of radiographic frontal sinusitis seen on postoperative imaging. A total of 8 patients (10%) in the MTsc group had measured mucosal thickening, which was increased from their preoperative scan versus 15 in the MTsp group (20%) (p = 0.10). New mucosal thickening of >1 mm was found in three patients in the MTsc group and eight patients in the MTsp group (p = 0.21); the only patient with postoperative complete frontal sinus opacification was in the MTsp group. CONCLUSIONS The choice of MTsc versus MTsp in endonasal endoscopic approach to the sella does not seem to make a difference in the incidence of postoperative radiographic frontal sinusitis.
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Affiliation(s)
- Leigh J Sowerby
- Department of Otolaryngology, Western University, London, Ontario, Canada
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Willson TJ, Fernandez-Miranda JC, Ferrareze Nunes C, Lieber S, Wang EW. Anatomic Considerations for Sinonasal and Ventral Skull Base Malignancy. Otolaryngol Clin North Am 2017; 50:245-255. [PMID: 28104275 DOI: 10.1016/j.otc.2016.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Malignancies of the sinonasal region and ventral skull base include a varied group of uncommon tumors that are a challenge to treat. These malignancies, with few exceptions, often present late because of their insidious growth and bland symptomatology. As with malignancies of other sites, the primary goal in surgical management is complete resection with negative margins. This presents a unique surgical challenge in that these lesions lie within a region of densely populated anatomic real estate. This fact reinforces the importance of complete preoperative work-up and a sound anatomic understanding. This article discusses key anatomic regions and their importance from an endonasal perspective.
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Affiliation(s)
- Thomas J Willson
- Department of Otolaryngology-Head & Neck Surgery, UPMC Eye & Ear Institute, University of Pittsburgh Medical Center, Suite 500, 203 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, UPMC Presbyterian, University of Pittsburgh Medical Center, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Cristian Ferrareze Nunes
- Department of Neurological Surgery, UPMC Presbyterian, University of Pittsburgh Medical Center, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Stefan Lieber
- Department of Neurological Surgery, UPMC Presbyterian, University of Pittsburgh Medical Center, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Eric W Wang
- Department of Otolaryngology-Head & Neck Surgery, UPMC Eye & Ear Institute, University of Pittsburgh Medical Center, Suite 500, 203 Lothrop Street, Pittsburgh, PA 15213, USA
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Miller AJ, Bobian M, Peterson E, Deeb R. Bleeding risk associated with resection of the middle turbinate during functional endoscopic sinus surgery. Am J Rhinol Allergy 2016; 30:140-2. [PMID: 26980395 DOI: 10.2500/ajra.2016.30.4273] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Anya J Miller
- Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, USA
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Chen FH, Deng J, Hong HY, Xu R, Guo JB, Hou WJ, Sun YQ, Lai YY, Li HB, Shi JB. Extensive versus functional endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps and asthma: A 1-year study. Am J Rhinol Allergy 2016; 30:143-8. [PMID: 26980396 DOI: 10.2500/ajra.2016.30.4271] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Feng-Hong Chen
- Allergy and Cancer Center, Otorhinolaryngology Hospital, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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The status of the middle turbinate and the risk of sinusitis after endoscopic transnasal sphenoidotomy. Eur Arch Otorhinolaryngol 2016; 274:1495-1499. [PMID: 27832338 DOI: 10.1007/s00405-016-4370-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
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.
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Fishpool SJC, Amato-Watkins A, Hayhurst C. Free middle turbinate mucosal graft reconstruction after primary endoscopic endonasal pituitary surgery. Eur Arch Otorhinolaryngol 2016; 274:837-844. [DOI: 10.1007/s00405-016-4287-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
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Halderman AA, Stokken J, Sindwani R. The effect of middle turbinate resection on topical drug distribution into the paranasal sinuses. Int Forum Allergy Rhinol 2016; 6:1056-1061. [PMID: 27255595 DOI: 10.1002/alr.21791] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/25/2016] [Accepted: 03/25/2016] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Ashleigh A Halderman
- Head and Neck Institute, Section of Rhinology, Sinus, and Skull Base Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Raj Sindwani
- Head and Neck Institute, Section of Rhinology, Sinus, and Skull Base Surgery, Cleveland Clinic Foundation, Cleveland, OH.
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Does septoplasty change the dimensions of compensatory hypertrophy of the middle turbinate? The Journal of Laryngology & Otology 2016; 130:554-9. [PMID: 27040842 DOI: 10.1017/s0022215116001055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To measure the dimensions of compensatory hypertrophy of the middle turbinate in patients with nasal septal deviation, before and after septoplasty. METHODS The mucosal and bony structures of the middle turbinate and the angle of the septum were measured using radiological analysis before septoplasty and at least one year after septoplasty. All pre- and post-operative measurements of the middle turbinate were compared using the paired sample t-test and Wilcoxon rank sum test. RESULTS The dimensions of bony and mucosal components of the middle turbinate on concave and convex sides of the septum were not significantly changed by septoplasty. There was a significant negative correlation after septoplasty between the angle of the septum and the middle turbinate total area on the deviated side (p = 0.033). CONCLUSION The present study findings suggest that compensatory hypertrophy of the middle turbinate is not affected by septoplasty, even after one year.
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Soler ZM. Editorial: Studying the spectrum of allergic and rhinologic disease. Am J Rhinol Allergy 2014; 28:447-8. [PMID: 25514479 DOI: 10.2500/ajra.2014.28.4134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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