Partial endoscopic middle turbinectomy augmenting functional endoscopic sinus surgery WILLIAM R. LAMEAR, MD, WILLIAM E. DAVIS, MD, MSPH, JERRY W. TEMPLER, MD, JOEL P. MCKINSEY, BS, and HERBIERTO DEL PORTO, Columbia, Missouri

Endoscopic sinus surgery has gained acceptance in the otolaryngologic community as an effective and safe method of treating inflammatory disease of the paranasal sinuses. At our institution, partial endoscopic middle turbinectomy has become a standard component of the procedure and our experience is reported. Middle turbinectomy enhances surgical exposure, specific anatomic anomalies are more completely corrected, and subpopulations of patients at risk for failure because of their underlying disease enjoy decreased rates of synechiae formation and closure of the middle meatus antrostomy when followed over time. Photodocumentation of the surgical technique and a discussion regarding the impact of middle turbinectomy on normal nasal physiology are presented. It is reported that the procedure is safe, and no complications directly attributable to middle turbinectomy (including atrophic rhinitis) are reported in a series of 298 patients. (OTOlARYNGOL HEAD NECK SURG 1992;107:382.)

The literature credits Hartman with having performed the first turbinate surgery in the 1870's.1 Subsequently, there have been periods during which inferior turbinectomy is both condemned/ and championed.F'" The otolaryngologic literature contains several references reporting complications caused by inferior turbinectomy, the most feared of which is atrophic rhinitis, or rhinitis sicca. This complication is probably the result of over zealous resection of the inferior turbinates, whose function is indeed important to normal nasal physiology. Partial middle turbinectomy has been advocated by Wigand et al. 9 and Toffel et al. 10 as part of a complete ethmoidectomy. It should be noted that there is only one report of a serious complication attributed to middle turbinectomy in the literature. 11 A case report describes a patient who underwent middle turbinectomy for headache without a preoperative CT scan. She had an unrecognized ethmoid encephalocele and a cerebrospinal

From the Division of Otolaryngology, University of MissouriColumbia School of Medicine. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Kansas City, Mo., Sept. 2226, 1991. Received for publication Oct. 10, 1991; accepted March 6, 1992. Reprint requests: William R. LaMear, MD, Tucson Ear, Nose, and Throat, 6565 East Carondolet, Suite 300, Tucson, AZ 85710.

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fluid leak developed postoperatively that was repaired transnasally with uneventful recovery. The emphasis of this article is on the statistical effect of middle turbinectomy on patency of surgically created ostia and synechiae formation, as well as the nasophysiologic consequences of its resection. Anatomy and Nasal Physiology

The nose is a dynamic organ consisting of mucosa, its underlying supportive tissue, and a bony skeleton. Anatomically, the middle turbinate is significantly smaller than the inferior, and accounts for a modest percentage of the nasal mucosa surface area. The inferior turbinate contains more vascular and erectile tissue and is considered to be a more dynamic structure. 4 Comparative anatomists have studied the turbinate structure of the nose of human beings and of other mammals.F:" The area of the seal's nasal turbinate mucosa, for example, exceeds its body surface area. Many animals rely on the elaborate and highly developed nasal turbinates for important thermoregulatory functions as the primary method of maintaining the organism's temperature in a hostile environment. In light of these comparisons, some investigators conclude "the inferior turbinate of the human (is) a rather insignificant organ, "12 and the human concha have even been called vestigial. The nose, which accounts for 47% of the total airway resistance;" can be mathematically modeled to consist

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Fig. 1. Post-resection photograph of middle turbinate illustrates natural ostia of maxillary sinus, excellent exposure of lateral nasal wall, and preservation of attachment of middle turbinate.

of a series of resistors. The internal nasal valve, which is created by the relationship of the septal and upper lateral cartilages, contributes to 50% of the total nasal resistance. 15.16 Recent investigators have added to our understanding of nasal airway resistance by reporting that the main site of respiratory resistance is at the anterior level of the inferior turbinates. 17 It can be concluded that the internal nasal valve plus inferior turbinate accounts for a very large percentage of the total nasal airway resistance, and that the middle turbinate accounts for a negligible portion. IS While there is some debate as to the function of the turbinates in the human nose, there is general agreement that collectively they serve to direct airflow, humidify and warm inspired air, and provide some defense against offending particulate matter by means of the functioning of the mucociliary transport system.i' Also, there is local immunologic response, as documented by measurable secretory IgA in nasal secretions. Because of the middle turbinate's modest surface area, decreased density of erectile and vascular tissue, less prominent position in the patterns of nasal airflow, and anatomic differences as compared to other mammals, it can be concluded that the middle turbinate is of less functional significance than its inferior partner.

METHODS AND MATERIAL

Endoscopic partial middle turbinectomy is accomplished before uncinectomy as in a modified Messerklinger approach. The nasal mucosa is topically prepared using 0.5% phenylephrine, 4% cocaine. One percent lidocaine with epinephrine (1 : 100,000) is injected into the inferior margin of the middle turbinate. Maximal hemostatic effect is obtained by waiting 5 minutes. Turbinate scissors are used to resect approximately one half to two thirds of the middle turbinate (see Fig. 1). When a concha bullosa is encountered, otologic cupped forceps are used to complete the resection of the intraturbinate mucosa. Middle meatotomy, ethmoidectomy, and sphenoidotomy are then completed, as indicated. It is important to note that preservation of an adequate remnant of the middle turbinate attachment is critical to the safety of the procedure. This serves as an important landmark, defining extent of the ethmoidectomy, position of the orbit, and roof of the nasal cavity. Nasal packing is routinely placed and removed on either postoperative day 1 or 2. Patients are followed closely in the office for the first 2 weeks. Crusts are removed, bacitracin ointment is applied, and healing occurs within 2 weeks. Typical postoperative appearance is shown in Fig. 2.

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Fig. 2. Typical postoperative appearance of partially resected middle turbinate and middle meatotomy,

Table 1. All patients: Failure = closure of middle meatotomy Time Interval (mo)

No. of patients at risk

No. of sides at risk

No. of sides failing

Percent failing

Cumulative patency (0/0)

0 3 6 12 18 24 30 36

298 283 210 152 101 67 38 22

509 486 352 256 172 113 63 36

11 8 1 2 0 1 0

2.3 2.3 0.4 1.2 0.0 1.6 0.0

100.0 97.4 95.5 95.1 94.0 94.0 92.5 92.5

Table 2. Patients with polyps: Failure = closure of middle meatotomy Time Interval (mo)

No. of patients at risk

No. of sides at risk

No. of sides failing

Percent failing

Cumulative patency (0/0)

0 3 6 12 18 24 30 36

144 140 117 90 65 45 25 17

257 250 203 154 112 79 44 30

8 8 1 1 0 1 0

3.2 3.9 0.7 0.9 0.0 23 0.0

100.0 96.8 93.0 92.4 91.6 91.6 89.5 89.5

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PATIENTS WITH POLYPS FAILURE • CLOSURE OF MIDDLE MEATOTOMY CUMULATIVE % FAILURES 15

10

5

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6

9

12

15

18

21

24

27

30

33

36

MONTHS POST-OPERATIVELY

I

~ WITH POLYPS

---+- WITHOUT POLYPS

I

Fig. 3. Graph illustrates failure rates of patients with and without polyps,

Table 3. Patients without polyps: Failure = closure of middle meatotomy Time interval

(mol

o 3 6 12 18 24 30 36

No. o{patients at risk

No. of sides at risk

No. of sides failing

Percent failing

CumUlative patency (%1

154 143 93 62 36 22 13 5

252 236 149 102 60 34 19 6

3 0 0 1 0 0 0

13 0,0 0,0 1,7 0,0 0,0 0,0

100,0 98,7 98,7 98.7 97,1 97,1 97,1 97,1

Chi-square analysis comparing groups in Tables 2 and 3 No, of sides

Open

Failed

Total

With polyps Without polyps

231 232

19 4

250 236

Chi-squared = 93893; p < 005

The charts of all patients who underwent functional endoscopic sinus surgery (FESS) between January 1987 and March 1991 were reviewed. A protocol had been established and required that patients be endoscopically examined at postoperative intervals of 3, 6, 12, 18, 24, 36, and 48 months. Attempts were made to contact all patients by telephone or mail. Patients were asked to complete surveys at yearly intervals. Background data

regarding allergy history, skin and RAST testing, allergy treatment, preoperative endoscopic examination, and nasal surgical history were collected. The scope of the surgical procedure, blood loss, and intraoperative findings, including complications, were similarly tabulated. The data were collected and, together with the results of the surveys, entered into a computer database (Foxpro, Fox Software, Inc., Perrysburg, Ohio).

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Table 4. All patients with middle turbinectomy: Failure = closure or synechiae formation Time interval (mo)

No. of patients at risk

No. of sides at risk

0 3 6 12 18 24 30 36

206 199 132 82 42 20 7 2

335 324 201 126 63 27

No. of sides failing

Percent failing

22 8 2 3 1 0 0

6.8 4.0 1.6 4.8 3.7 0.0 0.0

9 3

Cumulative patency (%)

100.0 93.2 89.5 88.1 84.0 80.1 801 80.1

Table 5. All patients without middle turbinectomy: Failure = closure or snyechiae formation Time Interval (mo)

No. of patients at risk

No. of sides at risk

0 3 6 12 18 24 30 36

116 107 92 79 67 51 31 18

174 162 140 119 101

No. of sides failing

Percent failing

6 5 5 5 3 3 1

3.7 36 4.2 5.0 3.8 6.3 36

79 48 28

Cumulative patency (%)

100.0 963 92.9 89.0 84.6 81.3 76.3 73.5

Chi-square analysis comparing groups in Tables 4 and 5 No. of sides

Open

Failed

Total

With middle turbinectomy Without middle turbinectomy

288

36

324

134

28

162

Chi-squared = 3.5989; P < 0.07

RESULTS

Two-hundred ninety-eight patients who had a primary diagnosis of chronic sinusitis underwent functional endoscopic sinus surgery during the study period. Follow-up examinations were continued until June 1991. Patients were considered to be eligible for study if they returned for at least one follow-up appointment at a minimum of 3 months postoperatively. The vast majority of patients met these criteria and 283 were available for study. The entire patient population is represented in Table 1. For the purposes of this study, patients were divided into three groups: all patients, those who had undergone middle turbinectomy, and those who did not. Multivariate analysis of the data was

performed using the variables: polyps, seasonal allergy, perennial allergy, allergy desensitization, nasal packing, blood loss, headache, and deviated septum. The dependent variable initially consisted of closure of the middle meatotomy, or failure of middle meatotomy patency. Because of the low overall failure rate- meaning closed middle meatotomy-a second and third analysis were performed, creating additional groups of patients. In the second group, a failure was considered to be a significant synechia formation. The third group consisted of those patients who had either a closed middle meatotomy or a significant synechia formation that nearly obstructed the middle meatus. This was considered consequential because of the observation that a

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Table 6. Patients with chronic sinusitis with middle turbinectomy: Failure = closure or synechiae formation Time Interval (mo)

No. of patients at risk

No. of sides at risk

No. of sides falling

Percentage failing

0 3 6 12 18 24 30 36

61 59 32 18 6 2 2 0

98 95 49 28 11 2 2 0

4 1 0 2 0 0 0

4.2 2.0 0.0 18.1 0.0 0.0 0.0

Cumulative patency (%)

100.0 95.8 93.8 938 76.8 76.8 76.8 76.8

Table 7. Patients with chronic sinusitis without middle turbinectomy: Failure = closure or snyechiae formation Time Interval (mo)

o 3 6 12 18 24 30 36

No. of patients at risk

No. of sides at risk

No. of sides falling

Percent falling

Cumulative patency ('Yo)

25 19 16 13 11 7 4 1

33 25 22 19 16 11 6 1

0 1 2 3 0 1 0

0.0 4.5 10.5 18.6 0.0 16.7 0.0

100.0 100.0 95.4 85.4 69.4 69.4 57.8 57.8

Chi-square analysis comparing groups in Tables 6 and 7 No. of sides

Open

Failed

Total

With middle turbinectomy Without middle turbinectomy

88

7

95

18

7

25

Chi-squared = 8.1748; P < 0.05

synechia formation often preceded complete closure of the meatotomy. Tables 2 through 7 contain data comparing only those groups of patients that multivariate analysis with chisquare comparison exhibited significance. The variables compared, i.e., polyps vs. no polyps, or middle turbinectomy vs. no middle turbinectomy, are indicated. The data are then presented graphically. DISCUSSION

Multivariate analysis of the entire group of patients finds that certain subgroups of patients are at increased risk for failure after endoscopic sinus surgery. Patients

with nasal polyps-and especially bilateral nasal polyposis-are at the highest risk for failure of any group. Figure 3 illustrates that patients with polyps have an 11.0% level of complete closure of the middle meatotomy at 36 months, whereas patients without polyps failed at a rate of only 3%. While we had expected middle turbinectomy to improve patency in this highrisk group-and the data suggest that-the results are not statistically significant. It can be concluded, however, that all patients who underwent middle meatotomy with middle turbinectomy are benefitted at a degree that is statistically significant. The data in Tables 4 and 5 indicate that if a

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OlolaryngologyHead and Neck Surgery

al.

ALL PATIENTS FAILURE • CLOSURE OR SYNECHIAE FORMATION CUMULATIVE

'l(,

FAILURES

35,---------------------------, 30 25

20 15 10

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o

3

6

9

12

15

18

21

24

27

30

33

36

MONTHS POST-OPERATIVELY -

WITH MIDDLE TURB

-+- WITHOUT MIDDLE TURB

I

Fig. 4. Graph illustrates failure rates of all patients with and without middle turbinectomy.

patient had a middle turbinectomy, a synechiae developed or the middle meatotomy closed at a rate 10% less than if no turbinectomy were done. This is graphically depicted in Fig. 4. This improved patency rate is most statistically significant in the subgroup of patients with a sole diagnosis of "chronic sinusitis"; that is, no polyps and no allergy. Tables 6 and 7, illustrated as Figure 5, demonstrate these findings. The group with middle turbinectomy had a decreased rate of synechiae formation or antrostomy closure that remained level after 18 months postoperatively, whereas if no middle turbinectomy was performed, there was a continued rate of failure that approached 50% by 36 months. In light of reports in the literature regarding serious problems associated with inferior turbinectomy, the question must be asked as to why middle turbinectomy appears to be without similar complications. First, from a nasophysiologic perspective, the middle turbinate has been shown to be less functionally significant than the inferior. Second, the middle turbinate is subtotally resected, thus assuring conservation of the fovea and preservation of intranasal landmarks. Third. there is only a small area of denuded ciliated epithelium created that studies? have shown are subsequently replaced by ciliated respiratory epithelium. If a larger scar had been formed, this regeneration may not have occurred and this could explain why some series of radical inferior turbinectomy have been accompanied by atrophic rhinitis and significant nasal crusting. Surveys were mailed to 298 patients, with a response rate of 63%. There were no reports of significant nasal crusting and overall, at 2 years postoperatively, 93%

of patients who had middle turbinectomy responded that they were better, compared with 88% of patients who did not have middle turbinectomy. These results were not statistically significant when chi-square analysis was applied. There were no instances of decreased smell or taste in this series of patients. In addition to the groups of patients that benefit from middle turbinectomy because of certain diagnosis, there are certain other patients who present anatomic challenges to the endoscopic sinus surgeon. These include a high septal deviation of the perpendicular plate of ethmoid obstructing the middle meatus, a patient with a narrow nasal vault, a septal spur impinging on the middle turbinate, and large concha bullosa. Middle turbinectomy affords improved exposure in these difficult patients. SUMMARY Our experience with endoscopic middle turbinectomy has been described in a series of 298 patients followed for up to 3 years. Overall cumulative patency of the entire patient population is 92.5% at 36 months postoperatively. Patients with polyps have the highest rate of closure of the middle meatotomy and, while not statistically significant, partial middle turbinectomy improves patency in these patients. In addition, patients with the sole diagnosis of chronic sinusitis, and the group "all patients" have a decreased rate of synechiae formation or closure of the antrostomy when middle turbinectomy is performed. We have experienced middle turbinectomy to be a useful adjunctive procedure in treatment of patients with inflammatory disease of the paransal sinuses and one

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PATIENTS WITH CHRONIC SINUSITIS FAILURE· CLOSURE OR SYNECHIAE FORMATION CUMULATIVE % FAILURES 60 ,----------------------~

50

40 30

20 10

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Partial endoscopic middle turbinectomy augmenting functional endoscopic sinus surgery.

Endoscopic sinus surgery has gained acceptance in the otolaryngologic community as an effective and safe method of treating inflammatory disease of th...
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