Middle turbinate resection: impact on outcomes in endoscopic sinus surgery.

Abstract

There is considerable controversy concerning the advisability and efficacy of middle turbinate resection in endoscopic sinus surgery. Some have reported that it causes an increase in the incidence of frontal sinusitis while others have .found no such association. Surprisingly, in a 35-year review of turbinate surgery literature, Clement and White did not find a single prospective study of turbinate surgery. In this article, we briefly report our prospective study of middle turbinate resection during endoscopic sinus surgery. Our findings lead us to believe that middle turbinate resection has no deleterious effects on the results of endoscopic sinus surgery.

Introduction

There is considerable disagreement concerning the advisability and efficacy of middle turbinate resection in endoscopic sinus surgery. Messerklinger felt that with few exceptions, the middle turbinate should be preserved. (1) Among these exceptions were cases of concha bullosa and a paradoxically bent middle turbinate; in such eases, partial resection was recommended. Wigand et al, on the other hand, recommended partial or total middle turbinectomy as a routine early step in endoscopic sinus surgery. (2) However, neither Messerklinger nor Wigand et al provided any scientific rationale for their respective approaches. Nevertheless, both techniques have yielded excellent results.

The recent literature has not clarified the controversy. Swanson et al reported an increased incidence of frontal sinusitis following middle turbinate resection. (3) Others have found no such association and, in fact, have reported an increase in middle mental patency rates. (4,5) But all of these studies were retrospective and therefore subject to the usual limitations of such investigations. In fact, in a review of 35 years of articles on turbinate surgery, Clement and White did not find a single prospective study. (6) In this article, we briefly describe the results of the first prospective study of middle turbinate resection during endoscopic sinus surgery.

Patients and methods

Our study population consisted of 31 consecutive patients who had bilateral, symmetrical chronic sinusitis that had not responded to medical management. Computed tomography revealed that disease in all patients involved at least the ethmoid and maxillary sinuses.

Endoscopic sinus surgery was performed by the senior author (D.H.R.) in the usual manner with one exception--the right middle turbinate was resected and the left middle turbinate was undisturbed. Resection of the right middle turbinate was performed in a modified Wigand fashion as described by Fortune and Duncavage, (4) while treatment of the left middle turbinate was performed as recommended by Messerklinger. (1) Thus, each patient served as his or her own control.

Results

All patients were followed for a period of 6 months to 2 years. Eight patients developed postoperative adhesions--four on the right, three on the left, and one bilaterally. Four patients experienced one episode each of bilateral sinusitis during the follow-up period; only one case involved the frontal sinus. All cleared rapidly with antibiotic therapy.

Discussion

Much of the controversy surrounding middle turbinate resection seems to involve matters of philosophy and personal beliefs concerning nasal physiology. Real evidence-based data are scant. As noted earlier, neither Messerklinger nor Wigand et al offered any solid scientific reasons for their disparate and strongly held beliefs. Much of the controversy may exist because the precise physiology of the middle turbinate is poorly understood. Clearly, the mucus blanket carries trapped particles to the pharynx while it also humidifies and warms inspired air. What is less certain is the relative plasticity of the nasal tissue and its ability to assume this function in the absence of the middle turbinate. There is also a point at which the loss of nasal tissue cannot compensate, a condition known as empty-nose syndrome.

Over the years, many authors have observed that there is more to the problem than concha bullosa and a paradoxically bent middle turbinate. In these situations, resection of the middle turbinate seemed to be beneficial. Furthermore, no deleterious effects have been observed by most authors. But the conservative thinkers among us worry about inadvertent harm from over-resection of nasal tissue.

Our prospective study was performed to provide some answers. Because reputable rhinologists both decry and advocate middle turbinate resection, we selected patients who had bilaterally symmetrical disease. The right middle turbinate was always resected and the left was always undisturbed in order to eliminate any selection bias.

Based on our findings, it would appear that middle turbinate resection has no deleterious effects on the results of endoscopic sinus surgery--at least in the absence of other complicating factors, such as a loss of additional nasal tissue.

References

(1.) Messerklinger W. Endoskopische diagnose and chirurgie der rezidivierender sinusitis. In: Krajira Z, ed. Advances in Nose and Sinus Surgery. Zagreb: Zagreb University, 1985.

(2.) Wigand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopical control: From radical operation to rehabilitation of the mucosa. Endoscopy 1978;10:255-60.

(3.) Swanson P, Lanza DC, Kennedy DW, Vining EM. The effect of middle turbinate resection upon frontal sinus disease. Am J Rhinol 1995;9:191-5.

(4.) Fortune DS, Duncavage JA. Incidence of frontal sinusitis following partial middle turbinectomy. Ann Otol Rhinol Laryngol 1998; 107:447-53.

(5.) Havas TE, Lowinger DS. Comparison of functional endonasal sinus surgery with and without partial middle turbinate resection. Ann Otol Rhinol Laryngol 2000; 109:634-40.

(6.) Clement WA, White PS. Trends in turbinate surgery literature: A 35-year review. Clin Otolaryngol 2001;26:124-8.

From the Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles.

Reprint requests: Dale H. Rice, MD, 1200 N. State St., Box 795, Los Angeles, CA 90033. Phone: [phone]; fax: [phone]; e-mail: [e-mail]