Endoscopic physiologic approach to allergy-associated chronic rhinosinusitis: A preliminary study.Abstract
Patients with allergy-associated chronic rhinosinusitis respond poorly to functional endoscopic sinus surgery functional endoscopic sinus surgery Functional endonasal endoscopic sinus surgery ENT A procedure that removes diseased nasal cavity and paranasal sinus tissue and restores mucociliary clearance Applications Chronic and/or recurrent sinusitis in Pts who fail (FESS), probably because of the altered nasosinus ventilatory physiology and the increased contamination of the nasosinus mucosa by the offending allergens. With this in mind, we describe the concept and technique of functional endoscopic en·do·scope
An instrument for examining visually the interior of a bodily canal or a hollow organ such as the colon, bladder, or stomach.
en nasosinus surgery (FENS) in such cases. The advantages of this technique are that it preserves the uncinate process, it limits ethmoidal ethmoidal
pertaining to the ethmoid bone.
enzootic ethmoidal tumor
see enzootic ethmoidal tumor.
carries the ethmoidal nerve as it re-enters the cranial cavity. exenteration exenteration /ex·en·ter·a·tion/ (ek-sen?ter-a´shun)
1. surgical removal of the inner organs; evisceration.
2. in ophthalmology, removal of the entire contents of the orbit. via a transbullar approach, and it simultaneously corrects both septal septal /sep·tal/ (sep´tal) pertaining to a septum.
Of or relating to a septum or septa. and lateral wall pathologies. The aim of our randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. prospective study was to subjectively and objectively compare the efficacy of FESS and FENS in 64 patients with allergy-associated chronic rhinosinusitis. Subjective assessment was ascertained by visual analog scores, and objective assessment was made by nasal endoscopy. In this preliminary study, we found that FENS was superior to FESS in treating chronic sinusitis associated with nasal allergy .
The evolution of nasosinus endoscopes and an improvement in our understanding of nasosinus pathophysiology pathophysiology /patho·phys·i·ol·o·gy/ (-fiz?e-ol´ah-je) the physiology of disordered function.
1. in chronic sinusitis have revolutionized the treatment of sinus disease. Stammberger  in Europe and Kennedy  in the United States have standardized and popularized the Messerklinger technique described in 1978, which is now accepted worldwide. Although functional endoscopic sinus surgery (FESS) provides good results in cases of chronic nonallergic rhinosinusitis, its results are poor in patients with allergy-associated chronic sinusitis.
According to Stammberger and Posawetz, allergic disease of the upper airway is not a primary indication for FESS.  They advocate FESS as an adjuvant therapy in patients who do not respond to hyposensitization hyposensitization
decreasing the hypersensitivity response to allergens by exposure, usually as intradermal injections, to minute but increasing doses of the allergens. A treatment modality for atopic dermatitis, most commonly in dogs, cats and horses. Called also desensitization. and antiallergic an·ti·al·ler·gic
Preventing or relieving allergies.
antiallergic adjective Countering allergy or an allergic state therapy. In such cases, they stress the need for a limited surgical procedure to treat the stenosis in the middle meatus and ethmoid ethmoid /eth·moid/ (eth´moid)
1. sievelike; cribriform.
2. the ethmoid bone; see Table of Bones. .ethmoi´dal
eth·moid or eth·moi·dal
Nishioka et al found that the polyp polyp, in medicine, a benign tumor occurring in areas lined with mucous membrane such as the nose, gastrointestinal tract (especially the colon), and the uterus. Some polyps are pedunculated tumors, i.e. recurrence rate was higher following FESS in allergic patients.  Levine reported better results in cases of chronic sinusitis than in cases of polyposis polyposis /pol·yp·osis/ (pol?i-po´sis) the formation of numerous polyps.
familial polyposis , familial adenomatous polyposis .  Our own experience with FESS in chronic sinusitis reveals that nasal allergy heralds a poor prognosis. A second look into the nasosinus ventilatory physiology, which is considerably altered in post-FESS cases, explains the reason for its failure. Removal of the uncinate process hypothetically exposes the operated ethmoid cavity and the major sinuses to allergens and bacteria-contaminated inspiratory in·spi·ra·to·ry
Of, relating to, or used for the drawing in of air.
pertaining to or used in the inspiration of air into the lungs. airflow. This leads to allergen allergen /al·ler·gen/ (al´er-jen) an antigenic substance capable of producing immediate hypersensitivity (allergy).allergen´ic
pollen allergen exposure to a larger surface area, which causes increased or persistent mucosal disease.
In this article, we stress the need for a proper case selection for FESS, and we emphasize the need to view cases of chronic sinusitis associated with nasal allergy more cautiously and skeptically. We advocate functional endoscopic nasosinus surgery (FENS) as an adjuvant adjuvant /ad·ju·vant/ (aj?dbobr-vant) (a-joo´vant)
1. assisting or aiding.
2. a substance that aids another, such as an auxiliary remedy.
3. modality of treatment in cases that are refractory to pharmaco- and immunotherapeutic measures. FENS involves the simultaneous endoscopic treatment of the turbinates and septum septum /sep·tum/ (sep´tum) pl. sep´ta [L.] a dividing wall or partition.
alveolar septum interalveolar s. to relieve the nasal obstruction associated with allergy and a limited sinus surgery that preserves the uncinate process. This modified endoscopic surgery protects the mucosa of the sinuses from allergen exposure during inspiration without compromising the clearance of ethmoidal disease. This technique perhaps favors better ventilation of the sinuses in the more sterile and allergen-free expiratory ex·pi·ra·to·ry
Of, relating to, or involving the expiration of air from the lungs.
relating to or employed in the expiration of air from the lungs. phase than in the more contaminated and allergen-carrying inspiratory phase.
Rationale for FENS
The vertical jet of inspired air spreads in a wide and gentle curve from the internal nasal valve toward the choanae. During quiet inspiration, the flow becomes laminar laminar /lam·i·nar/ (lam´i-nar)
1. pertaining to a lamina or laminae.
3. of, pertaining to, or being a streamlined, smooth fluid flow. at the valve area, and the direction becomes horizontal. Most of the airflow occurs along the middle meatus and floor of the nose, with less turbulence. The conformity of the lateral wall to the shape of the septum tends to keep the passage narrow and of uniform width, thereby promoting laminar flow. This thin laminar flow facilitates the exchange of temperature and humidity between the turbinates and the inspired air.  The expired air is more turbulent and flows throughout the nasal cavity. The sinuses are ventilated ven·ti·late
tr.v. ven·ti·lat·ed, ven·ti·lat·ing, ven·ti·lates
1. To admit fresh air into (a mine, for example) to replace stale or noxious air.
2. in the expiratory rather than inspiratory phase. 
The accompanying diagrammatic representation of airflow during the two phases of respiration in the nasal cavity and sinuses clearly shows the role of the uncinate process in directing the inspired air away from the sinuses, thus protecting them (figure 1). The uncinate process probably also directs the expired air into the infundibulum infundibulum /in·fun·dib·u·lum/ (-dib´u-lum) pl. infundib´ula [L.]
1. a funnel-shaped structure.
2. conus arteriosus.
3. i. of neurohypophysis. and the maxillary max·il·lar·y
Of or relating to a jaw or jawbone, especially the upper one.
A maxillar; a jawbone.
adj ostium ostium /os·ti·um/ (os´te-um) pl. os´tia [L.] an opening or orifice.os´tial
ostium abdomina´le tu´bae uteri´nae . Inspired air carries allergens and bacteria. Expired air is more sterile and allergen-free because it is "pretreated" by the respiratory mucosa. Thus, the sinuses are normally ventilated by a more sterile and allergen-free air. Moreover, an important and hitherto unrecognized function of the paranasal sinuses is that they provide a continual supply of fresh, uncontaminated mucus to the middle meatus so that mucociliary activity is preserved. 
Removal of the anterior part of the middle turbinate turbinate /tur·bi·nate/ (-nat)
1. shaped like a top.
2. any of the nasal conchae.
tur·bi·nate or tur·bi·nat·ed
1. Shaped like a top.
2. , as suggested by LaMear et al,  and the uncinate process exposes the sinuses to the rather contaminated inspired air. This is what hypothetically occurs in post-FESS patients, in whom the area of allergen deposition is greatly enhanced, extending into the sinuses. This might be the reason for the persistent postnasal drip and the increase in respiratory symptoms in post-FESS patients.
Keeping this in mind, the aims of FENS are (1) to preserve the uncinate process and anterior end of the middle turbinate, thereby protecting the sinuses from the contaminated inspired air; (2) to allow better ventilation of the sinuses in the expiratory phase by resecting the inferolateral part of the middle and inferior turbinates, which does not disrupt the laminar inspiratory flow because the conformity between the septum and lateral wall is preserved; (3) to treat sinus disease with a limited resection; and (4) to concomitantly treat the septal deformity via an ultraconservative approach aided by endoscopes.
FENS operative technique
In our study, all but seven FENS patients received local anesthesia. For vasoconstriction vasoconstriction /vaso·con·stric·tion/ (-kon-strik´shun) decrease in the caliber of blood vessels.vasoconstric´tive
n. and topical anesthesia, each patient's nose was sprayed with 4% lidocaine lidocaine /li·do·caine/ (li´do-kan) an anesthetic with sedative, analgesic, and cardiac depressant properties, applied topically in the form of the base or hydrochloride salt as a local anesthetic; also used in the latter form as a with 1:25,000 epinephrine. Cottonoid packs soaked in 4% lidocaine with 1:25,000 epinephrine were also placed. The surgical target sites were infiltrated with 2% lidocaine with 1:100,000 epinephrine. In all procedures, 4-mm, 0[degrees] and 30[degrees] nasal telescopes were used. The surgical procedure involved the simultaneous treatment of the pathologic septa septa /sep·ta/ (sep´tah) [L.] plural of septum.
Septum (plural, septa)
The dividing partition in the nose that separates the two nostrils. It is composed of bone and cartilage. , turbinates, and sinuses endoscopically.
Septal correction. After infiltration, a hemitransfixation incision was made. Septal deviations were corrected endoscopically. A hemitransfixation incision was made on the concave side in an S-shaped deviation. However, for a posterior deviation, a C-shaped spur was made on the convex side. The septal flap was elevated. Ultraconservative resection of the septal pathology was performed whenever indicated. Alignment of the septum was achieved by wedge resection, trimming, or crisscross incisions. 
After surgical treatment of the turbinates and the sinuses, the septal flaps were kept apposed ap·pose
tr.v. ap·posed, ap·pos·ing, ap·pos·es
To place in proximity; juxtapose.
[Probably ad- + -pose (as in compose).] and splinted with dental wax plates, which had been sterilized ster·il·ize
tr.v. ster·il·ized, ster·il·iz·ing, ster·il·iz·es
1. To make free from live bacteria or other microorganisms.
2. in glutaraldehyde glutaraldehyde /glu·ta·ral·de·hyde/ (gloo?tah-ral´de-hid) a disinfectant used in aqueous solution for sterilization of non-heat–resistant equipment; also used as a tissue fixative for light and electron microscopy. and cut to fit the nasal cavity.  These splints splints
inflammation of the interosseous ligament between the small and large metacarpal bones of horses and an accompanying periostitis and exostosis production on the small metacarpal bone. The metatarsal bones are similarly but less frequently involved. were anchored together to the septum by a through-and-through stitch with 2-0 catgut catgut or gut, cord made from the intestines of various animals (especially sheep and horses, but not cats). The membrane is chemically treated, and slender strands are woven together into cords of great strength, which are used for stringing or silk approximately 1.5 to 2 cm posterior to the caudal caudal /cau·dal/ (kaw´d'l)
1. pertaining to a cauda.
2. situated more toward the cauda, or tail, than some specified reference point; toward the inferior (in humans) or posterior (in animals) end of the body. end of the septum.
Turbinoplasty. In all cases, the inferior turbinate was trimmed inferolaterally, and the end that projected toward the nasopharynx nasopharynx /na·so·phar·ynx/ (-far´inks) the part of the pharynx above the soft palate.nasopharyn´geal
n. was amputated as described by Nayak et al.  The inferolateral portion of the middle turbinate was also resected in the middle and posterior areas (figure 2).
The concha bullosa was resected laterally. Submucous diathermy diathermy (dī`əthûr'mē), therapeutic measure used in medicine to generate heat in the body tissues. Electrodes and other instruments are used to transmit electric current to surface structures, thereby increasing the local blood was performed at the anterior end of the inferior turbinate--at times even to a polypoidal middle turbinate. Diathermy of the raw stump of the trimmed turbinates helped achieve hemostasis hemostasis /he·mo·sta·sis/ (he?mo-sta´sis) (he-mos´tah-sis)
1. the arrest of bleeding by the physiological properties of vasoconstriction and coagulation or by surgical means.
2. . Too much resection of the middle turbinate was avoided to maintain its stability.
Sinus surgery. Unlike FESS, FENS allows the surgeon to preserve the uncinate process. The anterior ethmoid cells were exenterated to the extent possible by a curved curette cu·rette or cu·ret
A surgical instrument shaped like a scoop or spoon, used to remove tissue or growths from a body cavity.
To scrape tissue or a body part with a curette. and upturned forceps. The maxillary ostium was visualized with a 30[degrees] endoscope endoscope, any instrument used to look inside the body. Usually consisting of a fiber-optic tube attached to a viewing device, endoscopes are used to explore and biopsy such areas as the colon and the bronchi of the lungs. , usually anteroinferiorly to the bulla bulla /bul·la/ (bul´ah) pl. bul´lae [L.]
1. a blister; a circumscribed, fluid-containing, elevated lesion of the skin, usually more than 5 mm in diameter.
2. a rounded, projecting anatomical structure. ethmoidalis in the hiatus semilunaris. When it was found, it was widened posteriorly and inferiorly. When the maxillary ostium could not be found, a curved spoon or fine cannula cannula /can·nu·la/ (kan´u-lah) a tube for insertion into a vessel, duct, or cavity; during insertion its lumen is usually occupied by a trocar.
can·nu·la or can·u·la
n. pl. was used to palpate pal·pate
To examine by feeling and pressing with the palms of the hands and the fingers.
pal·pation n. and probe the ostium just lateral to the inferior attachment of the uncinate process and inferior to the bulla. If the maxillary ostium still could not be located, the posterior aspect of the uncinate process was partially trimmed with a backward-cutting forceps to expose the natural ostium area (figure 3).
The posterior fontanelle was opened with a sickle knife, and the backward-cutting forceps were reintroduced to enlarge the antrostomy to join the natural ostium. A large middle meatal antrostomy was created until the roof of the antrum antrum /an·trum/ (an´trum) pl. an´tra, antrums [L.] a cavity or chamber.an´tral
cardiac antrum was well visualized (figure 4). Care was taken to preserve the uncinate process. When an accessory ostium was also found, the bridge of tissue between it and the natural ostium was removed. (An accessory ostium seen through a 0[degrees] scope itself should not be confused with the true ostium, which opens near the roof of the antrum.)
When computed tomography (CT) and diagnostic nasal endoscopy found no disease, the ethmoid sinuses were not exenterated. When indicated, exenteration was performed via a transbullar approach with a 30[degrees] scope. This is unlike the Messerklinger and Wigand techniques, which are anteroposterior anteroposterior /an·tero·pos·te·ri·or/ (-pos-ter´e-er) directed from the front toward the back.
adj. Abbr. AP
1. Relating to both front and back. and posteroanterior approaches, respectively.  The bulla was found to be the most constant ethmoidal cell and the key area for approaching either the anterior or the posterior group of air cells. The bulla was first punctured inferomedially and later exenterated with caution after the surgeon identified the lamina papyracea and the roof of the ethmoids. Identification of these structures was very easy via the transbullar approach. Using the fovea, lamina papyracea, and the middle meatal antrostomy as landmarks, the remainder of the ethmoids and sphenoids were exenterated when indicated (figure 5). A diseased frontal sinus and/or recess necessitated exenteration of even a normal bulla for proper access. A 30[deg rees] scope and an upturned forceps were used between the middle turbinate and lateral wall just posterior to the uncinate process to open the frontal recess and then the frontal sinus. It was not difficult to clear the frontal recess disease and create a frontal sinusotomy despite the uncinate process preservation. Occasionally, a 90[degrees] scope was used to visualize the frontal recess better. The posterior ethmoids and sphenoids were exenterated only when indicated.
Dental wax plates were used as a spacer between the middle turbinate and the lateral wall, in the manner described by Nayak et al,  whenever the development of synechiae was anticipated. Packing of the nasal cavity was not necessary except in three patients, who exhibited an ooze from the resected stump of the inferior turbinate. This was controlled by placing a cottonoid soaked in bismuth bismuth (bĭz`məth) [Ger. Weisse Masse=white mass], metallic chemical element; symbol Bi; at. no. 83; at. wt. 208.9804; m.p. 271.3°C;; b.p. about 1,560°C;; sp. gr. 9.75 at 20°C;; valence +3 or +5. iodoform iodoform (īō`dəfôrm'), CHI3, yellow crystalline solid that has a penetrating odor. It melts at 119°C; and is insoluble in water but soluble in ether or ethanol. Iodoform was formerly used as an antiseptic. paraffin paste, which was removed after 8 to 12 hours.
Materials and methods
We identified 120 patients with allergy-associated chronic rhinosinusitis who had been treated between January 1993 and December 1996 at Kasturba Hospital in Manipal, India. These patients had not responded to medical treatment. They were prospectively randomized into one of two groups (60 patients in each); one group underwent FESS as described by Stammberger,  and the other underwent FENS.
Sixty-four of these patients were available for a followup of 6 months or more--30 in the FESS group and 34 in the FENS group. Each patient was evaluated by a detailed history, clinical examination, nasal endoscopy, and radiology of the paranasal sinuses. None of them had a history suggestive of food allergy. In each case, sinus disease was confirmed by CT. Every patient had a positive allergic skin test, and each either had undergone or were undergoing hyposensitization and other antiallergic therapy. Patients who had frank nasal polyposis on anterior rhinoscopy were excluded from this study.
The two groups were age- and sex-matched. All patients were subjectively evaluated pre- and postoperatively with a visual analog scale. Objective evaluation was performed by nasal endoscopy. A topical budesonide nasal spray was advised for all patients postoperatively for a minimum of 3 months. Maintenance therapy with cromolyn sodium nasal spray or a systemic antihistamine antihistamine (ăn'tĭhĭs`təmēn), any one of a group of compounds having various chemical structures and characterized by the ability to antagonize the effects of histamine. was advocated in most cases, depending on the response. A few patients required intermittent short courses of systemic steroids.
Of the 120 patients, 64 were available for a followup of at least 6 months (range: 6 mo to 6 yr)--30 patients in the FESS group and 34 in the FENS group. All of these patients had symptoms of perennial allergy and chronic sinusitis, and most had headache, anterior nasal discharge, nasal obstruction, postnasal drip, and sneezing To verbally tell somebody about a new and interesting Web site. See viral marketing. spells (table I). A few patients also had hyposmia and wheezing Wheezing Definition
Wheezing is a high-pitched whistling sound associated with labored breathing.
Wheezing occurs when a child or adult tries to breathe deeply through air passages that are narrowed or filled with mucus as a .
Six of the FESS patients underwent septoplasty during a different sitting, while three underwent septal surgery concurrently. The conventional Messerklinger technique was used for all FESS patients, and the extent of ethmoid exenteration was guided by CT. Twenty-four patients underwent middle meatal antrostomy, and six patients underwent a total sphenoethmoidectomy.
All 34 of the FENS patients underwent turbinoplasty, and 22 had a septal correction. All 34 had a middle meatal antrostomy--28 with an ethmoidectomy and 6 without. Of the 28 patients who underwent an ethmoidectomy, 22 had an anterior ethmoidectomy, 4 had an anterior and posterior ethmoidectomy, and 2 others had an anterior and posterior ethmoidectomy in addition to a sphenoidotomy.
Subjective evaluation. The criteria for surgical cure in the literature differ widely, from symptomatic improvement to complete resolution. Therefore, the statistical significance of success rates in different studies cannot be compared. We categorized our subjective postoperative results as either resolved, improved, unchanged, or worse (table 2). Our subjective evaluations were aided and documented by comparisons with each patient's pre- and postoperative visual analog scores. The statistical significance of the differences between the numbers of patients whose symptoms had resolved and those whose symptoms had not resolved was calculated according to the [[chi].sup.2] tests with Yates' correction.
The resolution rates for headache, nasal obstruction, and postnasal drip were significantly greater in the post-FENS group than in the post-FESS group. Anterior nasal discharge, sneezing spells, hyposmia, and wheezing were not significantly resolved by either surgery. However, there was a significant difference in favor of FENS in patients with sneezing and wheezing when the percentage of those whose symptoms resolved was combined with the percentage of those whose symptoms improved (p[less than or equal to]0.05).
Objective evaluation. Postoperative followup evaluation by nasal endoscopy documented the outcomes of both surgeries, and it showed that FENS was clearly superior to FESS (table 3). However, the poor response in the FESS group might have been attributable to a much worse underlying allergy and to the greater extensiveness of the surgery. No orbital complication or cerebrospinal fluid rhinorrhea cerebrospinal fluid rhinorrhea
A discharge of cerebrospinal fluid from the nose. was encountered during or after either surgery.
Messerklinger's endoscopic approach to the nasal sinuses is well established. [14, 15] This procedure involves the removal of the uncinate process, clearance of the ethmoid disease, and the creation of frontal and maxillary sinusotomies. Although this technique is quite suitable and effective in cases of nonallergic chronic sinusitis, its efficacy in allergy-associated chronic rhinosinusitis is questionable.
Allergic rhinitis is one of the most common coexisting conditions in patients with chronic sinusitis, and it is also seen in some patients with bronchial asthma. [16,17] In a review of published results of endoscopic sinus surgery, Terris and Davidson documented the presence of allergies in 14 to 58% (mean: 40%) of patients with chronic sinusitis. 
All patients with allergy-associated chronic sinusitis should be given an adequate course of treatment with pharmaco- and immunotherapy, which are the mainstays of treatment. In patients who do not respond to immunotherapy, the probability of an IgG-mediated food and/or mold allergy should be considered.
Surgical treatment is indicated in refractory cases as the last resort to relieve obstruction and infection.  Stammberger and Posawetz advocated a limited endoscopic sinus surgery as an adjuvant treatment.  Such an operation helps to modify minor obstructive anatomic variants, but it has no effect on the allergy. [16,17] Shambaugh viewed the new sinus operations for allergic rhinitis with great skepticism.  Indeed, the efficacy of FESS in allergy-associated chronic rhinosinusitis is not impressive in the literature. Davis et al observed extended postoperative recovery times and decreased antrostomy patencies in patients operated on during a period of high antigen exposure.  In a significant study, Nishioka et al found that a higher incidence of polyp recurrence occurred in allergic cases following FESS.  It has also been reported that patients with diffuse rhinosinopathy and primary eosinophilic eosinophilic /eo·sin·o·phil·ic/ (-fil´ik)
1. readily stainable with eosin.
2. pertaining to eosinophils.
3. pertaining to or characterized by eosinophilia. infiltration are more likely to develop recurrent disease following endoscopic sinus surgery. [17 ]
Allergy associated with chronic rhinosinusitis is seen frequently in our center. Earlier treatment modalities included submucosal submucosal /sub·mu·co·sal/ (-mu-ko´sal)
1. pertaining to the submucosa.
2. beneath a mucous membrane. diathermy, partial or total inferior turbinectomy, and intraturbinal corticosteroid corticosteroid /cor·ti·co·ster·oid/ (-ster´oid) any of the steroids elaborated by the adrenal cortex (excluding the sex hormones) or any synthetic equivalents; divided into two major groups, the glucocorticoids and injections as an adjunct to pharmaco- and immunotherapy. Refractory sinus disease in such cases was treated by conventional intra- and/or extranasal procedures. Our results, unfortunately, never showed that patients experienced a complete relief of symptoms.
When FESS came into vogue, it was overenthusiastically adv. 1. In an excessively enthusiastic manner. performed, even in cases of allergy-associated chronic rhinosinusitis. Although FESS produced good results in patients with nonallergic rhinosinusitis, it was disappointing in those with allergy-associated chronic rhinosinusitis. (In fact, the senior author [D.R.N.] is one such patient.) The poor post-FESS outcomes prompted us to rethink the pathophysiology of allergy-associated chronic rhinosinusitis, the rationale for FESS in such cases, and the reasons for its failure. As a result of this reconsideration, we began to combine modified conventional surgical techniques (submucosal diathermy and/or a partial inferior turbinectomy) with a judicious use of modified endoscopic sinus surgery to treat such cases. This technique eventually gave rise to the evolution of FENS.
Nasal turbinate hypertrophy hypertrophy (hīpûr`trəfē), enlargement of a tissue or organ of the body resulting from an increase in the size of its cells. Such growth accompanies an increase in the functioning of the tissue. is often associated with allergy, more so in patients who also have bronchial asthma. Septoturbinal compression is associated with middle turbinate syndrome, and middle turbinate hypertrophy results in an obstruction that alters the normal flow of air and mucus.  The inferior turbinates in the allergic nose are the primary shock organs that cause nasal obstruction.  To deal with such turbinates, many techniques have been advocated: intraturbinal steroid injections, submucosal diathermy, surface cautery cautery, searing or destruction of living animal tissue by use of heat or caustic chemicals. In the past, cauterization of open wounds, even those following amputation of a limb, was performed with hot irons; this served to close off the bleeding vessels as well as of the inferior turbinate, bipolar cautery of the turbinate, chemical cautery with agents such as silver nitrate, outfracture of the turbinate, submucosal resection of the inferior turbinate, partial inferior turbinectomy, and endoscopic partial inferior turbinectomy with a powered microcutting instrument.  Some surgeons perform partial endoscopic middle turbinectomy in all cases as a standard component of FESS.  LaMear et al, in discussing the impact of middle turbine ctomy on the normal nasal physiology, wrote that this procedure is safe and does not cause postoperative atrophic rhinitis.  A concha bullosa is trimmed by a partial resection of its lateral aspect. 
In our series, we performed an inferolateral partial resection and amputation amputation (ăm'pyətā`shən), removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly of the posterior end of the inferior turbinate to facilitate the flow of inspiratory air in the inferiormost part of the nasal cavity and to allow for the passage of allergen-free expired air through the middle meatus. The inferolateral trimming of the middle turbinate with preservation of the anterior end helps provide better ventilation of the sinuses during the expiratory phase.
The success of FENS in allergy-associated chronic rhinosinusitis might be explained by the protection of the sinuses from allergen exposure during the inspiratory phase and the better ventilation of the sinuses in the allergen-free sterile expiratory phase. Long-term success depends on control of the primary cause (i.e., the allergy) rather than repeated surgeries to treat pathologic changes. Thus, short courses of systemic steroids and maintenance treatment with nasal steroid sprays, cromolyn sprays, mucolytics, anticholinergics, and/or suitable antihistamines Antihistamines Definition
Antihistamines are drugs that block the action of histamine (a compound released in allergic inflammatory reactions) at the H1 help provide long-term relief. Local and systemic decongestants Decongestants Definition
Decongestants are medicines used to relieve nasal congestion (stuffy nose).
A congested or stuffy nose is a common symptom of colds and allergies. also provide immediate relief of symptoms, but they cannot be used on a long-term basis because of their side effects.  Immunotherapy is promising because it provides long-term symptomatic relief, but it does not statistically influence middle meatotomy patency pa·ten·cy
The state or quality of being open, expanded, or unblocked.
the condition of being open. , synechiae formation, or recurrence of polyps Polyps
A tumor with a small flap that attaches itself to the wall of various vascular organs such as the nose, uterus and rectum. Polyps bleed easily, and if they are suspected to be cancerous they should be surgically removed. following FESS.  Although our preliminary findings are encouraging, a larger series over a longer duration is required to determine its efficacy accurately.
In conclusion, FESS is not the panacea for all sinus disorders, and its role has been overemphasized. In allergy-associated chronic rhinosinusitis, FESS actually aggravates allergic symptoms. We found FESS to be more troublesome than beneficial because of the incidence of persistent or even increased postnasal drip. This was probably the result of the increase in mucosal surface area that became available for allergen exposure plus the drying effect of the increased volume of air as a result of overzealous turbinate resection and total ethmoidectomy.
FENS, on the other hand, provides a safe and efficient method of relieving obstruction in the nasal passage and osteomeatal complex. At the same time, it protects the sinuses from allergen exposure, ventilating ventilating
Natural or mechanically induced movement of fresh air into or through an enclosed space. The hazards of poor ventilation were not clearly understood until the early 20th century. Expired air may be laden with odors, heat, gases, or dust. them during an allergen-free expiratory phase. It is not merely a viable alternative in the management of allergy-associated chronic rhinosinusitis, it is a superior alternative.
The authors thank Dr. Ramdas Pai, medical director at Kasturba Hospital, and Prof. P. Hazarika, professor and head of the Department of ENT ENT ears, nose, and throat (otorhinolaryngology).
ear, nose, and throat
ear, nose and throat.
ENT Ears, nose & throat; formally, otorhinolaryngology at the Kasturba Medical College Kasturba Medical College (KMC), is a medical college based in Manipal, Udupi District Karnataka, India.In fact they are two separate medical colleges run by same T.M.A foundation( formerly General Academy of Education ).
Established by Dr T.M.A. , for their contributions to this study. We also thank Mrs. A. Thulasi for her secretarial assistance.
From the Department of ENT-Head and Neck Surgery, Kasturba Medical College, Manipal, Karnataka, India.
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Table 1. Preoperative symptoms in 30 FESS and 34 FENS patients FESS FENS Total n (%) n (%) n (%) Headache 28 (93.3) 31 (91.2) 59 (92.2) Anterior nasal discharge 26 (86.7) 32 (94.1) 58 (90.6) Nasal obstruction 28 (93.3) 25 (73.5) 53 (82.8) Postnasal drip 24 (80.0) 21 (61.8) 45 (70.3) Sneezing spells 17 (56.7) 27 (79.4) 44 (68.8) Hyposmia 13 (43.3) 15 (44.1) 28 (43.8) Wheezing 11 (36.7) 12 (35.3) 23 (35.9) Table 2. Subjective postoperative evaluation: Number of patients and the degree of change in symptoms FESS (n = 30) Symptoms R * I U W Total Headache 7 13 6 2 28 Anterior nasal discharge 6 14 5 1 26 Nasal obstruction 4 7 16 1 28 Postnasal drip 3 5 12 4 24 Sneezing spells 0 2 14 1 17 Hyposmia 2 2 9 0 13 Wheezing 0 2 6 3 11 FENS (n = 34) Symptoms R I U W Total Headache 17 8 6 0 31 Anterior nasal discharge 11 16 4 1 32 Nasal obstruction 13 9 3 0 25 Postnasal drip 12 7 1 1 21 Sneezing spells 5 9 13 0 27 Hyposmia 3 4 8 0 15 Wheezing 2 7 3 0 12 Symptoms p value+ Headache [less than]0.05 Anterior nasal discharge NS Nasal obstruction [less than]0.01 Postnasal drip [less than]0.01 Sneezing spells NS Hyposmia NS Wheezing NS (*)R = resolved I = improved U = unchanged W = worse (+)p value is calculated according to the [[chi].sup.2] test with Yates' correction and applies to the difference between those patients who resolved and those who did not. Table 3. Objective postoperative evaluation: Adverse endoscopic findings in 30 FESS and 34 FENS patients FESS FENS n (%) n (%) Residual disease Discharge 25 (83.3) 15 (44.1) Polypoidal musosa 13 (43.3) 3 (8.8) Polyp formation 8 (26.7) 1 (5.9) synechiae between the 6 (20.0) 2 (5.9) MT * and lateral well Persistent contact areas 6 (20.0) 2 (5.9) Sinusotomy closure 2 (6.7) 0 (*)MT = middle turbinate.