Conchopexy of middle turbinate versus bolgarization in endoscopic sinus surgery

Objectives The aim of this study is to assess the role of simple conchopexy suture in maintaining a widely patent middle meatus during the phase of postoperative healing (and its effect on olfaction); this enables delivery of topical medication and sinus aeration compared with functional endoscopic sinus surgery (ESS) with and without bolgarization of the middle turbinate (MT). Patients and methods This study included 39 patients. Patients were divided into three equal groups randomly; each group included 13 patients. Group A underwent ESS with suture medialization of the MT (method), group B underwent ESS with bolgarization of the MT, and group C underwent normal ESS. Items of comparison between the three groups included both subjective and objective parameters such as symptoms (nasal obstruction, facial pain, and smell) and endoscopy findings. All the patients underwent preoperative and 2-month postoperative assessment with a questionnaire, smell test, and endoscopic examination. Results In terms of nasal obstruction in all three groups, there was a statistically significant improvement (P = 0.001, 0.001, and 0.002, respectively). Improvement in facial pain was statistically highly significant in group A (P = 0.0007), whereas it improved significantly in groups B and C (P = 0.001 and 0.002, respectively). Improvement in smell was statistically insignificant in all three groups (P = 0.4). The postoperative endoscopy findings improved compared with the preoperative findings in all three groups. Conclusion MT conchopexy and bolgarization of the MT have no detectable adverse effects on olfaction. No lateral synechia was detected, and there was a highly significant improvement in facial pain scores were observed in patients who underwent concopexy; patients who underwent middle turbinate bolgarization also showed improvement in both aspects, but in a lower percent. Both conchopexy and bolgarization of the MT after conventional ESS may help improve postoperative ostiomeatal complex patency, mucosal healing, and minimize adhesions, with no adverse effect on olfaction.


Introduction
The middle turbinate (MT) lateralization is a common complication of endoscopic sinus surgery (ESS) that occurs when opposing areas of denuded mucosa form a scar between them. This scar pulls the MT laterally to the lateral nasal wall and may cause obstruction of the middle meatus and the maxillary, ethmoid, or frontal sinuses, which can result in failure of the initial procedure and often necessitates revision surgery [1,2].
The MT medialization is reliable and should be considered an alternative to turbinate resection [3]. It was also noted that MT medialization exerted no detectable adverse effect on olfaction, and turbinate medialization techniques have gained popularity in an attempt to prevent turbinate lateralization [4].
Current techniques for medialization of the MT include techniques that use pacers and packing, controlled scarring of the MT and adjacent septum (bolgarization), and suturing of the MT to the septum. Recently, a new technique allows insertion of a tiny resorbable implant that anchors the MT to the septum. The MediENT MT implant presents a simple and effective solution.
The aim of the present study is to compare between different methods of medicalization of the MT and their impact on postoperative signs and symptoms.

Objectives
The aim of this study is to assess the role of simple conchopexy suture in maintaining a widely patent middle meatus during the phase of postoperative healing (and its effect on olfaction); this enables delivery of topical medication and sinus aeration compared with functional endoscopic sinus surgery (ESS) with and without bolgarization of the middle turbinate (MT).

Patients and methods
This study included 39 patients. Patients were divided into three equal groups randomly; each group included 13 patients. Group A underwent ESS with suture medialization of the MT (method), group B underwent ESS with bolgarization of the MT, and group C underwent normal ESS. Items of comparison between the three groups included both subjective and objective parameters such as symptoms (nasal obstruction, facial pain, and smell) and endoscopy a questionnaire, smell test, and endoscopic examination.

Results
(P = 0.001, 0.001, and 0.002, respectively). Improvement in facial pain was statistically highly P (P three groups (P

Patients
Thirt-nine patients with chronic rhinosinusitis (CRS) that was refractory to ordinary medical treatment were enrolled in this study. Inclusion criteria were all patients with CRS who had failed medical treatment. Exclusion criteria were previous surgical treatment for CRS and findings suggestive of allergic fungal sinusitis.
Informed consent was obtained from all patients after approval of the study by the ethical committee. All procedures were performed at the ENT Department, Kasr Al Aini Hospital, Cairo University, during the period from December 2010 till May 2012.

Study design
The study was designed as a prospective randomized-controlled study. Patients were divided into three equal groups of 13 patients each.

Surgical technique
All surgeries were performed with the patient under general anesthesia. At the beginning of the surgery, the mucosa and nasal cavities were decongested using nasal packs with 1 : 100 000 saline adrenaline. A standard ESS technique was used.
Group A: 4-0 vicryl suture on a straight needle is passed through the MT from lateral to medial traversing the nasal septum to the contralateral side, then continued through the MT and brought out through the nose. It is then passed again in the opposite direction through the same structures and tied, thus securing the MTs tightly against the septum. Group B: The mucosa of the medial surface of the MT, just posterior to the turbinate caudal end, and the opposing septal mucosa are abraded with a sickle knife. This results in a denuded area measuring 3 × 3 mm on both surfaces. The MT is pushed medially and nasal packing is placed lateral to the MT to maintain its position for 24-48 h. This technique results in controlled synechia formation between the MT and the nasal septum. Group C: Conventional ESS.

Assessment parameters
Two main parameters were used to evaluate the efficacy of the treatment: symptoms and endoscopic scoring.
Preoperative and postoperative subjective outcomes of symptoms (nasal obstruction, facial pain, and olfaction) were assessed using the visual analogue scale.
Preoperative and postoperative objective assessments were performed by endoscopy before and 2 months after the operation in terms of inflammatory edema of the ostiomeatal complex (OMC), muco-pus in the middle meatus, and the presence of scarring and adhesions, which was quantified on 0-2-point basis (0 = not present, 1 = present, and 2 = marked).

Statistical analysis
Statistical presentation and analysis of the present study were carried out using SPSS v.16 (IBM, Armonk, New York, USA). Descriptive statistics were determine for all variables, including mean, SD, and range. The independent-sample Student t-test was used for the statistical analysis of all of our parametric variables. A P value of 0.05 or less was considered significant and a P value of 0.001 or less was considered highly significant.

Demographic data
Among the study population, there were 17 males (43.59%) and 22 females (56.41%). Patients ranged in age between 14 and 56 years, with a mean age of 31.8 ± 11.6 years. There was no statistical difference in ages between all groups.

Nasal obstruction
Preoperative nasal obstruction visual analogue scale of patients in group A ranged from 5 to 10, with a mean of 7.38 ± 1.76, and the postoperative score ranged from 0 to 4, with a mean of 0.85 ± 0.99; the improvement was found to be statistically significant (P = 0.001).
The preoperative values of patients in group B ranged from 5 to 8, with a mean of 6.38 ± 1.19, whereas postoperative values ranged from 0 to 3, with a mean of 0.77 ± 1.01; the improvement was found to be statistically significant (P = 0.001). The preoperative results of patients of group C ranged from 5 to 10, with a mean of 6.46± 1.66, whereas the postoperative results ranged from 0 to 4, with a mean of 1.85 ± 1.63, with statistical significance (P = 0.002).

Facial pain
The preoperative mean scores of patients in groups A, B, and C were 5.69 ± 2.25, 5.92 ± 1.44, and 6.15 ± 2.19, respectively; the postoperative mean scores showed improvement, which was statistically highly significant (P = 0.0007) in group A, statistically significant (P = 0.001) in group B, and statistically significant (P = 0.002) in group C.

Olfaction
In all three groups, there was an improvement in smell sensation, which was statistically insignificant (P = 0.04).
The preoperative endoscopic score of the patients in group A ranged from 2 to 6, with a mean of 4 ±1.53, whereas the postoperative endoscopic score ranged from 0 to 2, with a mean of 0.77 ± 0.83, with statistical significance (P = 0.002) (Figs. 1 and 2).
The preoperative endoscopic score of the patients in group B ranged from 2 to 6, with a mean of 3.46 ± 1.45, whereas the postoperative endoscopic score ranged from 0 to 3, with a mean of 1.15 ± 1.28, with statistical significance (P = 0.002) (Figs. 3 and 4).
In group C, the preoperative endoscopic score ranged from 2 to 6, with a mean of 3.85 ± 1.42, whereas the postoperative endoscopic score ranged from 0 to 4, with a mean of 1.62 ± 1.76, with statistical significance (P = 0.003) (Fig. 5 and Table 1).

Discussion
Lateralization of the MT with scarring and obstruction of the middle meatus after endoscopic ethmoidectomy accounts for a high percentage of postoperative complications [5].

Turbinate medialization techniques have gained popularity in an attempt to prevent turbinate
Straight needle in middle turbinate (MT) suturing in group A.

Figure 2
Bolgarization of the septum.  lateralization and MT medialization has no detectable adverse effect on olfaction [4].
Stabilization of MT with a turbinate trans-septal suture was performed in patients by 4-0 vicryl suture on a straight needle. Only one patient was noted to have lateralization of the MT on one side that necessitated further surgery despite excellent results; it was found that the initial success rate after ESS with suture stabilization of MT was 98% in to achieve a patent the middle meatus without synechia or maxillary sinus ostium obstruction postoperatively [5].
Another attempt at stabilization of MT with a turbinate trans-septal suture was made in 30 patients by 3-0 vicryl suture on a curved needle. It was found that OMCs were patent in 93.7% of patients. MT of two cases were lateralized because of parted suture. Four patients complained of hyposmia after surgery, which disappeared in the postoperative period [6].
The current study is complementary to a previous work. In this study, we compared different techniques of MT medicalization and their effect on symptoms and postoperative endoscopy findings. We studied three groups: group A underwent ESS with suturing medicalization of the MT, group B underwent ESS with bolgarization of MT, and finally, group C underwent conventional ESS. In our study, all three groups showed statistically significant improvements in nasal obstruction; also, there was no worsening of sense of smell. The patients in group A showed a highly statistically significant improvement in facial pain (P =0.0007), whereas the patients in both groups B and C showed a statistically significant improvement (P = 0.001 and 0.002, respectively).
The postoperative endoscopic findings in group A indicated complete resolution of mucosal edema and disappearance of mucopus in 100% of cases; none of our patients had scarring or adhesions. The patients in group B showed complete resolution of mucosal edema and disappearance of mucopus in 83% of cases; two patients had postoperative lateral synechia and adhesions (15%). Finally, the postoperative endoscopic findings of patients of group C showed complete resolution of mucosal edema (100%) and disappearance of mucopus in 60% of cases; five patients had postoperative lateral synechia and adhesions (38%). The results of our study are comparable with those obtained by Thorton and Kim's in terms of postoperative endoscopic findings. Also, our study showed that postoperative lateralization of the MT was prevented using conchopexy; this is in agreement with the work of Chen et al. [7], who concluded that turbinate suture medicalization of the MT after ESS is very effective against postoperative lateralization.
Dutton and Hinton [8], in their work in 2011, studied the effect of conchopexy on olfaction on a large number of patients and they reported that application of an MT suture does not exert any effect on olfactory functions.

Conclusion
MT conchopexy, bolgarization of the MT, and conventional ESS have no detectable adverse effects on olfaction. No lateral synechia and a highly significant improvement in facial pain scores were observed in patients who underwent concopexy; patients who underwent MT bolgarization also showed improvements in both aspects, but in a lower percent.
Although further studies should be carried out with a broader population of patients and with longer periods of close endoscopic and symptomatic follow-up, both conchopexy and bolgarization of the MT after conventional ESS may help improve postoperative OMC patency, mucosal healing, and minimize adhesions while having no adverse effect on olfaction. Adhesions in the middle meatus in group C.

Financial support and sponsorship
Nil.
There are no conflicts of interest.