Transseptal suture to secure middle meatal spacers.

Abstract

Middle meatal spacers are used by many sinus surgeons to aid postoperative care. Aspiration of a spacer is a concern. We demonstrate a novel method of securing spacers with a transseptal suture to prevent aspiration. We fashion each spacer from a powder-free, nonlatex glove finger that is packed with a Merocel sponge. The open end of the finger is closed with 2-0 Prolene sutures. For a bilateral procedure, the needle is left attached to one of the spacers. A spacer is placed in each ethmoid cavity, the attached needle is passed through the anterior cartilaginous septum, and the suture is tied to the suture on the opposite spacer. For unilateral procedures, the suture on the single spacer is passed to the contralateral side and tied on itself. One week later, the transseptal suture is cut and the spacers are removed. We performed this procedure on 78 patients who had undergone total ethmoidectomy. None of the spacers migrated during the I week they were in place. One patient complained of pain during removal of a spacer. During follow-up of 2 to 10 months, we found no evidence of injury to the septum at the site of the transseptal suture. We conclude that the transseptal suture is a safe and cosmetically superior method of securing middle meatal spacers.

Introduction

Lateralization of the middle turbinate following functional endoscopic sinus surgery can lead to a poor long-term outcome. Many strategies have been proposed to prevent lateralization, including turbinate resection, formation of controlled synechia (Bolgerization), and placement of dissolvable packing, a turbinate glove, or middle meatal spacers. (1-3)

Placement of middle meatal spacers has become our method of choice because of (1) its efficacy in preventing lateralization and synechia formation, (2) the ease with which it can be performed, and (3) the fact that postoperative debridement can be performed more quickly and with less pain. However, one concern expressed by surgeons who choose not to use middle meatal spacers is that the spacers might become dislodged and aspirated, which could lead to the need for foreign-body extraction or even death. Although no such occurrence has been reported in the literature, the aspiration of spacers has been discussed anecdotally.

In view of these concerns, we devised a method of preventing middle meatal spacer aspiration by placing a transseptal suture to secure the anterior edges of the packs. In this article, we describe our technique and we report our results in 78 patients.

Patients and methods

Technique. The spacers are fashioned from a finger cut from a powder-free nonlatex glove. The finger is packed with a 4-cm Merocel sponge, and the anterior edge of the spacer is closed with a 2-0 Prolene suture. The needle is left attached to one of the spacers.

We use middle meatal spacers only in patients who have undergone endoscopic total ethmoidectomy, either unilaterally or bilaterally. First, we create a controlled synechia between the middle turbinate and the septum (Bolgerization). (1) In bilateral cases, a spacer is introduced into each ethmoid cavity and secured by placing it over a strut of the basal lamella. The attached needle is passed through the anterior cartilaginous septum and tied intranasally to the suture on the opposite spacer (figure). In unilateral cases, the suture on the single spacer is passed to the contralateral side and tied on itself. One week later, the suture is cut, the spacers are removed, and endoscopic debridement is performed in the standard fashion.

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Study. We conducted a retrospective study of 78 patients--40 women and 38 men, aged 18 to 78 years (mean: 44.9)--who had received our middle meatal spacers after they had undergone total ethmoidectomy. The ethmoidectomies had been unilateral in 22 patients (28.2%) and bilateral in 56 (71.8%). Septoplasty had been performed concomitantly in 14 patients (17.9 %). In 4 patients (5.1%), ethmoidectomy had been performed as part of a cerebrospinal fluid leak/encephalocele repair. Follow-up ranged from 2 to 10 months (mean: 5).

Results

In no case did a spacer migrate out of position. During follow-up, no retained sutures or spacers were observed, and no septal perforations occurred. One patient complained of pain during spacer removal.

Discussion

Middle meatal spacers both stent the middle meatus and aid in hemostasis during the immediate postoperative period. Limiting the amount of blood clot in the middle meatus immediately after surgery decreases the amount of manipulation that is required to remove the clot during the first postoperative debridement; it also reduces the amount of time required to perform debridement and the amount of pain associated with debridement. When placement of a middle meatal spacer is performed as part of the controlled synechia technique, the contractile forces of healing within the ethmoid cavity are balanced. (1) The duration of stenting required to ensure adhesion between the middle turbinate and the septum depends on multiple factors, including the size of the abrasion made and the degree of middle turbinate instability. The senior author (J.N.P.) typically sees patients 1 week postoperatively for the first follow-up visit, and he removes the spacers at that time. Patients do not complain of discomfort associated with the spacers, and 1 week of stenting is more than adequate to ensure formation of an adequate synechial band. Another advantage of securing middle meatal spacers with a transseptal suture is that there is no need to tape strings to the face.

In conclusion, our technique is safe and easy to perform, it is cosmetically acceptable, and we believe it obviates any concern about spacer aspiration.

References

(1.) Bolger WE, Kuhn FA, Kennedy DW. Middle turbinate stabilization after functional endoscopic sinus surgery: The controlled synechiae technique. Laryngoscope 1999; 109:1852-3.

(2.) Brennan LG. Minimizing postoperative care and adhesions following endoscopic sinus surgery. Ear Nose Throat J 1996;75:45-8.

(3.) Kuhn FA, Citardi MJ. Advances in postoperative care following functional endoscopic sinus surgery. Otolaryngol Clin North Am 1997;30:479-90.

From the Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System and the University of Pennsylvania School of Medicine, Philadelphia.

Reprint requests: James N. Palmer, MD, Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, 34th and Spruce Sts., 5 Ravdin, Philadelphia, PA 19104. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Originally presented as a poster during the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery; Sept. 21-24, 2003; Orlando, Fla.

Neil G. Hockstein, MD; Christina B. Bales, MD; James N. Palmer, MD