Abstract
The middle turbinate is an important surgical landmark in functional endoscopic sinus surgery (FESS). Postoperatively, lateralization may obstruct the middle meatus, thereby increasing the risk of complications and recurrences. A new medialization technique using metallic clips between the head of the middle turbinate and the septum is described. The aim of this study is to evaluate the clip medialization technique applied in 56 cases of bilateral FESS. We think that this simple technique, with its low rate of complications, is an adequate and simple procedure for middle turbinate medialization. A good and accessible middle meatus was observed in 54 patients.
Sommaire
Le cornet moyen est un repere chirurgical important dans la chirurgie endoscopique des sinus. Une lateralisation postop&atoire peut obstruer le meat moyen et augmenter le risque de complications et recidives. Nous proposons et decrivons une nouvelle technique de medialisation utilisant des clips metalliques entre la tete du cornet moyen et le septum. Le but de cette etude est donc d'evaluer cette technique sur 56 interventions bilaterales. Nous pensons que cette technique simple et avec peu de complications est une procedure adequate pour medialiser le cornet moyen. Un meat moyen facilement accessible a ete note chez 54 patients.
Key words: clip medialization technique, middle turbinate, postoperative complications, sinus surgery
aranasal sinus surgery has improved dramatically over the past decade due to the development of diagnostic tools (i.e., computed tomography [CT] scan) and the introduction of sinus endoscopes.
Endoscopic surgery is a delicate and precise technique. This type of surgery is rendered much safer by keeping in mind important anatomic structure peroperatively.
The middle turbinate (MT) plays an important role in functional endoscopic sinus surgery (FESS). It is one of the most important landmarks to keep in view during surgery. This role is more critical in recurrent cases.'
On the other hand, one of the main postoperative complications of FESS is the lateralization of the MT, followed, at times, by the formation of adhesions between the MT and the lateral nasal wall leading to obstruction of the middle meatus and thereby of sinus ostium.2 Thus, MT collapse may jeopardize the success of the operation and predispose to recurrences of the pathology (Fig. 1).
The aim of our study is to evaluate a new medialization technique of the MT by the insertion of metallic clips between the MT and the septum. This technique will prevent early lateralization of MT, maintain adequate opening of the middle meatus, and allow good airflow and adequate drainage. Potential complications like infection, clips aspiration, anosmia, and airflow disturbances were also evaluated.
Materials and Methods Patients
A prospective study was conducted between 1996 and 1998 on 60 patients. Preoperative CT scan of paranasal sinus with axial and coronal views was obtained. Ten patients complained of hyposmia whereas two patients were completely anosmic. There were 33 males and 27 females. The mean age at the time of surgery was 36.7 years (range = 22-60 years). The mean follow-up was 11 months (range = 3-18 months). Of the 60 patients, 43 were found to have chronic sinusitis and 17 presented with nasal polyposis. Three cases of nasal polyposis have already undergone FESS at another institution.
All patients underwent bilateral endoscopic ethmoidectomy with middle meatal antrostomy in the standard fashion as described by Messerklinger.1 Septal deviation was present in 28 patients, 10 of whom underwent septoplasty during FESS to increase the accessibility to the operative field.
Surgical Technique
At the end of the operation, the MT on each side was medialized and pushed against the septum. The head of the MT was crushed. Care was taken not to injure the medial aspect of MT. A 1-cm incision was made in the septal mucosa facing the head of the MT on each side. The mucoperichondral flap was elevated for a short distance and two surgiclips were used to fix the head of the MT to the septal mucoperichondral flap. The insertion of the clips was done using either the nasal endoscope (Storz 300) or the head's light.
Two types of clip were used: premium surgiclipautosuture (USSC) and Ligaclip Extra LT 400 (Ethicon). Nasal packing was not needed unless concomitant septoplasty was done. Patients were seen on a weekly basis for 6 weeks postoperatively. Patients were instructed that metallic clips might fall from their nose at one time postoperatively.
Results
Our clip medialization technique was used in 56 patients. In the three recurrent cases, the MT was polypoid and partial middle turbinectomies were done. In one case, the septal cartilage was missing during the dissection of septal mucosa. We elected not to apply our proposed procedure in order to prevent septal per(oration. This patient has already undergone submucosal resection (SMR).
The mean delay for the fall of the clips was 28 days, with an average of 3 to 6 weeks. In two cases, the clips fell at days 8 and 10 postsurgery. Fifty-four of the 56 patients had an accessible middle meatus at their last follow-up (Figure 2). In two cases, we had lateralization of the MT after the fall of the clips, but none developed recurrent sinusitis.
Success of this procedure was defined as patency of the middle meatus 4 weeks postoperatively, demonstrated by the ability to insert a number 7 FR suction easily into the middle meatus. On the other hand, failure of this procedure was observed in two patients (i.e., inability to insert a number 7 FR suction into the middle meatus 1 month postsurgery). No clip aspiration was noted. However, 11 patients were aware of the fall of their clips while blowing their noses. Infection was never observed at the site of clip insertion. No cases of hematoma, abscess, or septal perforation were noted postoperatively.
Synechia between the medial aspect of MT and septum was noted in one case and was excised at the office. No other complications were observed. Postoperatively, the anosmic patients remained unchanged, whereas 7 of the 10 hyposmic cases recovered completely. No induced smell problems were encountered as a complication of our technique.
Discussion
The lateralization of the MT following FESS may compromise the success of the operation. In fact, the lateralization occurs in 43% of cases, leading in 7% to the formation of synechia between the MT and lateral nasal wall.3-s
In order to understand the dynamics of lateralization of the MT, it is helpful to review the anatomic characteristics of the MT. The MT is subdivided into an anterior buttress, a vertical MT attachment, a lateral attachment (basal lamella), and a posterior buttress.6 The MT anterior buttress is its anterior insertion to the lateral nasal wall just below the agger nasi region. The vertical portion of the MT attaches to the cribriform plate superiorly and provides stability for the anterior MT. The MT basal lamella attaches to the lamina papyracea and extends all the way down to the posterior buttress. This is where the posterior MT inserts into the lateral nasal wall.
During FESS, the integrity of these attachments is weakened. This is primarily due to two surgical steps: the dislocation of the MT medially during the access to the middle meatus and the penetration of the MT basal lamella to reach the posterior ethmoid cells. This will result in having a MT fixed only through its vertical attachment. The MT will be prone to retract laterally as scar tissue contracts, pulling it against the medial orbital wall.
Many techniques have been proposed to resolve this problem. Some authors have advocated frequent postoperative visits with cleaning of the middle meatus and lyses of adhesions.6-9 This may be uncomfortable for the patient, time consuming, and may, at times, cause further trauma and scarring. Jebeles and Hicks proposed placement of synthetic sponges in the middle meatus for extended periods.7 Patient discomfort, obstruction of the nasal antral window, and ostiomeatal outflow during healing are certainly a matter of concern. Shikani advocated the use of middle meatal antrostomy stent,8 whereas Brennan used the "Boomrang turbinate glove."9 These may cause foreign body reaction with resultant granulation tissue surrounding the stent and discomfort at the time of removal. Thornton recommended fixation of both turbinate to septum using a single thread.10 This is a technically demanding procedure. In their article, Kuhn and Citardi described the scarification technique,6 which consists of denuding the mucosal membrane of the medial aspect of the MT and the faced nasal septum. Merocel was used to keep the MT medially applicated to the septum, and then synechiae would form between the MT and nasal septum. The main disadvantage is that patients may ultimately need a second procedure to excise synechiae. Others proposed partial or complete resection of MT to solve the issue. This may clear the problem immediately but may produce crusting and drying in the postoperative period, requiring frequent irrigation for cleaning. However, the most important sequel would be the modifications of important anatomic landmarks mainly in recurrent cases.
The resection of MT can increase the risk of inadvertent complications in surgery for recurrent cases. On the other hand, some patients present with combined sinus and inferior turbinate pathology. Thus, we sometimes need to excise the inferior turbinate along with FESS. In these cases, partial or complete resection of MT is contraindicated, as it may increase the risk of ozena.
One of the most basic issues to consider in lateralization of MT, apart from its anatomic characteristics and its technical procedures in FESS, is the healing process. Cicatrization starts at 3 weeks postoperatively with contraction of the MT against the lateral nasal wall. Every attempt to medialize the MT must take into consideration this physiologic process.'
In our series, we have had two failures in which the clips fell before postoperative day 10. These were among the first cases where the incision of the mucoperichondral flap was more anteriorly done than required. With experience, we learned that making the incision just in front of the head of the MT will help better fixation of the clip to the septum, delaying the fall of the clip and thereby preventing early lateralization of the MT. In all other cases, the clips fell between 3 and 6 weeks, with one case at 3 months.
We do not recommend applying this procedure in cases where MT is polypoid. Also, for patients with a previous history of SMR, it is better to defer this procedure in order to avoid iatrogenic septal perforation. In these particular cases, we elect to perform partial middle turbinectomies.
No surgery-induced smell problems were noted. This is due to the fact that the medialization is only temporary and does not interfere with the smell pathway. It is noteworthy to mention that while crushing the head of the MT, it is important to avoid injuring the mucosa of the medial aspect of the MT in order to decrease the risk of synechiae.
In our series, clip insertion did not increase the incidence of nasal infection. This is essentially due to the noninterference with mucus nasal flow out. Also, frequent lavages of the nasal fossa were started early (day 1 postoperatively), which helped prevent infection development. When we started the application of this technique, our primary concern was the risk of clip aspiration. However, we did not encounter any case of clip aspiration.
One of the technical complications of the procedure is the damage of the 300 endoscope. When using this scope, the surgeon sees only the distal end of the Ligaclip. Unfortunately, the distal end of the scope may pass between the proximal branches of the Ligaclip. When closing the Ligaclip, the distal end of the scope is at risk of being crushed (Fig. 3). This happened in one case. After this, we preferred to use the much safer USSC autosuture in combination with the 300 endoscope. If USSC is not available, the Ligaclip is used in conjunction with the head's light.
Conclusion
This is a simple procedure, easy to apply with uneventful complications and successful avoidance of endoscopic sinus postoperative lateralization of MT.
Acknowledgement
We would like to acknowledge Rana Fakhoury for her assistance in the preparation of this manuscript.
References
1. Messerklinger W. Recurring rhinosinusitis: endoscopic diagnosis and surgery. Presented at the 13th World Congress of Otorhinolaryngology, Miami, FL, May 30, 1985.
2. Biedlingmaier JD. Endoscopic sinus surgery with middle turbinate resection: results and complications. Ear Nose Throat j 1993; 72:351-355.
3. Lazar RH, Younis RT, Long TE, et al. Revision functional endonasal sinus surgery. Ear Nose Throat J 1992; 71: 131-133.
4. Stankiewiez JA. Complications in endoscopic intranasal ethmoidectomy: an update. Laryngoscope 1989; 99:686-690.
5. Stankiewiez JA. Complications of endoscopic sinus surgery. Otolaryngol Clin North Am 1989; 22:749-758.
6. Kuhn FA, Citardi MJ. Advances in postoperative care following functional endoscopic sinus surgery. Otolaryngol Clin North Am 1997; 30:479-490.
7. Jebeles JJ, Hicks JN. The use of Merocel for temporary medialization of the middle turbinate during functional endoscopic sinus surgery. Ear Nose Throat J 1993; 72:145-146.
8. Shikani AH. A new middle meatal antrostomy stent for functional endoscopic sinus surgery. Laryngoscope 1994; 104:638-641.
9. Brennan LG. Minimizing postoperative care and adhesions following endoscopic sinus surgery. Ear Nose Throat J 1996; 75:45-48.
10. Thornton RS. Middle turbinate stabilization technique in endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 1996; 122:869-872.
Nabil Moukarzel, MD, Antoine Nebme, MD, FR CSC, FACS, Salah Mansour, MD, FR CSC, FACS, Fady G. Yammine, MD, and Alain Moukheiber, MD
Received 1916/99. Revised 31/7/99. Accepted for publication 15/9/99.
Nabil Moukarzel, Antoine Nebmg, Salah Mansour, Fady G. Yammine, and Alain Moukheiber: Division of ENT Surgery, Lebanese University, Hazmieh, Lebanon.
Presented at the 52nd annual meeting of the Canadian Society of Otolaryngology-Head and Neck Surgery, Montreal, Quebec, June 14-17, 1998.
Address reprint requests to. Dr. Nabil Moukarzel, Division of ENT Surgery, H6pital Sacre-Coeur, Brazilia-Baabda, B.P.: 116Hazmieh, Lebanon.
Copyright Decker Periodicals, Inc. Jun 2000