Resection versus preservation of the middle turbinate in surgery for chronic rhinosinusitis with nasal polyposis: a randomized controlled trial

Marc-Antoine Hudon, Erin D Wright, Etienne Fortin-Pellerin, Marie Bussieres, Marc-Antoine Hudon, Erin D Wright, Etienne Fortin-Pellerin, Marie Bussieres

Abstract

Background: Chronic rhinosinusitis (CRS) affects up to 16% of the population. When medical treatment fails, endoscopic sinus surgery (ESS) is considered. The value of resecting the middle turbinate to optimize surgical outcomes has been hypothesized but remains controversial and unproven. Whether the middle turbinate should be left in place or resected is controversial. Our objective is to determine if middle turbinectomy improves objective surgical outcomes after ESS.

Methods: Sixteen patients (15 men, 15 primary surgery) undergoing bilateral complete ESS for CRS with nasal polyposis were recruited. Nasal cavities were randomized so that middle turbinectomy was performed on one side while the middle turbinate was preserved on the other. Each participant acted as their own control. Nasal cavities were compared using Perioperative Sinus Endoscopy (POSE) and Lund-Kennedy (LKES) scores pre-operatively, and at 1, 3 and 6 months after ESS. Results were analyzed using Wilcoxon signed-rank test.

Results: Pre-operatively, the POSE (12.4 ± 2.9 vs 12.8 ± 2.6, p = 0.33, for the preserved side and the resected side, respectively) and LKES (5.0 ± 1.0 vs 4.8 ± 1.2, p = 0.33) scores were similar between sides. During follow up, resection was associated with more crusting at 1 month following ESS (1.0 ± 0.7 vs 0.4 ± 0.6, p = 0.02). There was a small, but statistically significant, difference between the nasal cavities at 3 months, where the resected side showed better endoscopic appearance (2.0 ± 2.2 vs 3.4 ± 2.8, p = 0.01). No difference was found at 6 months. Frontal sinus scores were similar between sides at 6 months (0.7 ± 0.5 vs 0.7 ± 0.5, p = 1.00).

Conclusion: Our results show no sustained objective endoscopic benefit of routine middle turbinectomy, at least within the first six postoperative months, in patients undergoing primary ESS for CRS with polyposis.

Trial registration: NCT, NCT02855931 . Registered 16 August 2016.

Keywords: Chronic rhinosinusitis; Endoscopic sinus surgery; Middle turbinate; Nasal polyposis.

Conflict of interest statement

Ethics approval and consent to participate

Approval was obtained by the Comité d’éthique de la recherche en santé chez l’humain du CIUSSS de l’Estrie – CHUS.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Sinonasal endoscopic outcomes after surgery. Trends for POSE (a) and LKES (b) scores over time. * First timepoint where scores within the same groups are statistically different from baseline. † Significant difference between groups at the indicated timepoint. POSE: Peri-Operative Sinus Endoscopy, LKES: Lund-Kennedy Endoscopic Score
Fig. 2
Fig. 2
Endoscopic outcomes of the frontal sinus/recess. Trends for frontal sinus/recess subcategory of the POSE score over time. * First timepoint where scores within the same groups are statistically different from baseline. POSE: Peri-Operative Sinus Endoscopy

References

    1. Halawi AM, Smith SS, Chandra RK. Chronic rhinosinusitis: epidemiology and cost. Allergy Asthma Proc. 2013;34:328–334. doi: 10.2500/aap.2013.34.3675.
    1. Caulley L, Thavorn K, Rudmik L, Cameron C, Kilty SJ. Direct costs of adult chronic rhinosinusitis by using 4 methods of estimation: results of the US medical expenditure panel survey. J Allergy Clin Immunol. 2015;136:1517–1522. doi: 10.1016/j.jaci.2015.08.037.
    1. Rudmik L, Soler ZM, Smith TL, Mace JC, Schlosser RJ, DeConde AS. Effect of continued medical therapy on productivity costs for refractory chronic rhinosinusitis. JAMA Otolaryngol Head Neck Surg. 2015;141:969–973. doi: 10.1001/jamaoto.2015.2321.
    1. Dautremont JF, Rudmik L. When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery. Int Forum Allergy Rhinol. 2015;5:1095–1103. doi: 10.1002/alr.21601.
    1. Jang DW, Lachanas VA, Segel J, Kountakis SE. Budesonide nasal irrigations in the postoperative management of chronic rhinosinusitis. Int Forum Allergy Rhinol. 2013;3:708–711. doi: 10.1002/alr.21189.
    1. Kennedy DW. Middle turbinate resection: evaluating the issues--should we resect normal middle turbinates? Arch Otolaryngol Head Neck Surg. 1998;124:107. doi: 10.1001/archotol.124.1.107.
    1. Fortune DS, Duncavage JA. Incidence of frontal sinusitis following partial middle turbinectomy. Ann Otol Rhinol Laryngol. 1998;107:447–453. doi: 10.1177/000348949810700601.
    1. Saidi IS, Biedlingmaier JF, Rothman MI. Pre- and postoperative imaging analysis for frontal sinus disease following conservative partial middle turbinate resection. Ear Nose Throat J. 1998;77:326–328.
    1. Wu AW, Ting JY, Platt MP, Tierney HT, Metson R. Factors affecting time to revision sinus surgery for nasal polyps: a 25-year experience. Laryngoscope. 2014;124:29–33. doi: 10.1002/lary.24213.
    1. Marchioni D, Alicandri-Ciufelli M, Mattioli F, Marchetti A, Jovic G, Massone F, Presutti L. Middle turbinate preservation versus middle turbinate resection in endoscopic surgical treatment of nasal polyposis. Acta Otolaryngol. 2008;128:1019–1026. doi: 10.1080/00016480701827541.
    1. Havas TE, Lowinger DS. Comparison of functional endonasal sinus surgery with and without partial middle turbinate resection. Ann Otol Rhinol Laryngol. 2000;109:634–640. doi: 10.1177/000348940010900704.
    1. Clement WA, White PS. Trends in turbinate surgery literature: a 35-year review. Clin Otolaryngol Allied Sci. 2001;26:124–128. doi: 10.1046/j.1365-2273.2001.00450.x.
    1. Cote DW, Wright ED. Triamcinolone-impregnated nasal dressing following endoscopic sinus surgery: a randomized, double-blind, placebo-controlled study. Laryngoscope. 2010;120:1269–1273.
    1. Soler ZM, Smith TL. Quality of life outcomes after functional endoscopic sinus surgery. Otolaryngol Clin N Am. 2010;43:605–612. doi: 10.1016/j.otc.2010.03.001.
    1. Hopkins C, Browne JP, Slack R, Lund V, Brown P. The Lund-Mackay staging system for chronic rhinosinusitis: how is it used and what does it predict? Otolaryngol Head Neck Surg. 2007;137:555–561. doi: 10.1016/j.otohns.2007.02.004.
    1. Lund VJ, Kennedy DW. Quantification for staging sinusitis. The staging and therapy group. Ann Otol Rhinol Laryngol Suppl. 1995;167:17–21. doi: 10.1177/000348949510410s02.
    1. Wright ED, Agrawal S. Impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis: evaluation with the novel perioperative sinus endoscopy (POSE) scoring system. Laryngoscope. 2007;117:1–28. doi: 10.1097/MLG.0b013e31814842f8.
    1. Byun JY, Lee JY. Middle turbinate resection versus preservation in patients with chronic rhinosinusitis accompanying nasal polyposis: baseline disease burden and surgical outcomes between the groups. J Otolaryngol Head Neck Surg. 2012;41:259–264.
    1. Soler ZM, Hwang PH, Mace J, Smith TL. Outcomes after middle turbinate resection: revisiting a controversial topic. Laryngoscope. 2010;120:832–837. doi: 10.1002/lary.20812.
    1. Kidwai SM, Parasher AK, Khan MN, Eloy JA, Del Signore A, Iloreta AM, Govindaraj S. Improved delivery of sinus irrigations after middle turbinate resection during endoscopic sinus surgery. Int Forum Allergy Rhinol. 2017;7:338–342. doi: 10.1002/alr.21894.
    1. Scangas GA, Remenschneider AK, Bleier BS, Holbrook EH, Gray ST, Metson RB. Does the timing of middle turbinate resection influence quality-of-life outcomes for patients with chronic rhinosinusitis? Otolaryngol Head Neck Surg. 2017;157:874–879. doi: 10.1177/0194599817706929.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe