Conchopexy Suture versus Bolgerization in preventing middle turbinate lateralisation following FESS*

Background: Middle turbinate lateralisation is the most common minor post-operative complication following functional endoscopic sinus surgery. This study aimed to compare the outcome between Conchopexy suture and Bolgerization method in preventing middle turbinate lateralisation. Methodology: This was a prospective, comparative and interventional study conducted from May 2018 to November 2019 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. A total of 68 patients were divided equally into two groups. Following functional endoscopic sinus surgery, the middle turbinate was medialised either by Conchopexy suture or Bolgerization technique. Postoperative assessment was done on the second and 12th week of surgery, where the position of the middle turbinate and status of the sinus cavity were assessed using perioperative sinus endoscopic (POSE) score. Chi-square test and unpaired t test were used for comparison of postoperative results between two groups taking p value of < 0.05 as statistically significant. Results: Lateralised middle turbinate and mean POSE score was 5/34 (14.8%) and 2.1±1.25, respectively, in Conchopexy group whilst in Bolgerization group it was 6/34 (17.6%) and 2.5±1.46. However, the observed differences were not statistically significant. Conclusion: Conchopexy suture and Bolgerization techniques were equally effective in preventing middle turbinate lateralisation. Hence, either of these techniques could be used as an adjunct to FESS to avoid middle turbinate lateralisation.


Introduction
Functional endoscopic sinus surgery (FESS) in chronic rhinosinusitis (CRS) is indicated when it fails to respond to primary medical therapy (1) . The middle turbinate (MT), which serves as an important landmark is medialised to gain wide access during FESS. Unfortunately, the MT can lateralise in 1-27% (2)(3)(4)(5) of cases postoperatively and is considered the most common complication. Lateralised MT is an untoward outcome as it obstructs osteomeatal complex hence, impairing the ventilation and drainage of sinuses and also preventing drug penetration to sinuses, which can consequently lead to increased revision surgery (4,5) .
To avoid this, several additional procedures like Conchopexy suture (6,7) , Bolgerization (8) , nasal pack (4) , bioresorbable implant (9) and bioglue (10) have been used to keep the middle turbinate medialised. Conchopexy suture and Bolgerization are widely used procedures with success rate of 90-92% and 88% respectively (4,6,7) . Conchopexy suture technique employs suturing of middle turbinate with nasal septum, which is preferred when the MT is unstable, however, it is technically difficult and lengthens operating time (11) . In Bolgerization technique, controlled synechiae is made between the middle turbinate and the nasal septum by creating a raw area over the antero-inferior part of middle turbinate and the adjacent nasal septum. Though this technique is easy to perform, it is associated with injury to unstable middle turbinate and bears the risk of septal perforation. Comparison of the effectiveness of these two procedures in preventing middle turbinate lateralisation following FESS has rarely been assessed, which this study aimed to assess. Allocation and execution of medialisation procedure (Conchopexy suture or Bolgerization)

Materials and methods
The medialisation procedure was randomly allocated before surgery. This involved picking up a paper from shuffled pieces of paper with either Conchopexy suture or Bolgerization written. Following FESS with or without septoplasty, the allocated procedure was done to medialise the MT on both sides. The patients were blinded with regards to the medialisation procedure allocated.
The Conchopexy suture procedure adopted in this study was described by Lindemann et al. (6) . Vicryl 3/0 (Ethicon) was passed through the antero-inferior part of middle turbinate and the adjacent nasal septum on one side and further passed through the antero-inferior part of middle turbinate on the other side. The suture was then traversed through the septum just anterior to the middle turbinate in patients who had FESS with septoplasty.
Whilst those who underwent FESS only, the suture was passed through the cartilaginous septum to avoid the difficulty in passing the suture through the perpendicular plate of ethmoid which remained intact as septoplasty was not done.
Similarly, Bolgerization, originally described by Bolger et al. (8) , was modified slightly in our study. Instead of using a sickle knife like Bolger did to create a 5x5 mm raw area on the medial aspect of antero-inferior portion of MT and adjacent nasal septum, microdebrider was used. Bilateral middle meatus was packed with three small pieces of polyvinyl nasal packs whilst the nasal cavity was additionally packed with one large polyvinyl nasal pack on each side irrespective of the medialisation procedure followed.
The nasal packs were removed after 48 hours postoperatively.

Outcomes assessed
On the second postoperative week (POW), crusts and secretions were cleared off the nasal cavity whilst the outcomes were

Statistical analysis
For comparison of outcomes between the two groups, unpaired t test and Chi-square test were used. SPSS version 23 was used to analyze the result and p < 0.05 was taken as statistically significant.

Results
A total of 70 patients were enrolled in our study during the study period however, two of them were lost for follow up on 12th POW. Hence, the outcome of 68 patients were assessed and analyzed. Both the Conchopexy suture and Bolgerization group had 34 patients each. None of the cases were revision cases.
The age of the patient ranged from 14 -70 years with a mean age of 36.26±13.74 years. Most of the patients fell in the 40 -50 years age group. There were 42 males and 26 females with male: female ratio of 1.6:1 (Table 1).

Primary outcome
In the Conchopexy suture group, the MT was lateralised in 5(14.8%) patients whilst in Bolgerization group, it was lateralised in 6(17.6%) patients. Although the lateralised MT was seen more in Bolgerization group, the difference was not statistically significant ( Table 2).

Secondary outcome
The mean POSE score in Conchopexy suture group was lower than in Bolgerization group, the difference being not statistically significant ( Table 2). The middle meatus, ethmoid and sphenoid sinuses were normal in more patients in Conchopexy suture group as compared to Bolgerization group, whilst normal frontal sinuses outnumbered in Bolgerization group as compared to Conchopexy suture group. However, these differences were not statistically significant (Table 3). Mucoid secretion was the most common unhealthy finding in these sinuses.

Age distribution
The most common age group affected by nasal polyposis in this  (12) at our institute in 2015 showed higher prevalence at a slightly younger age group of 31-45 years. This could be because the latter study included patients only up to 45 years of age. Bettega et al. (13) states fifth decade as the common age group to be affected. We cannot comment on the prevalence of nasal polyposis in extreme age groups as none of our patients fell in that category.

Gender distribution
In this study, males were affected more (61.8%) than females (38.2%) with male to female ratio being 1.6:1 which is similar to the study by Gyawali et al. (12) and Jahromi et al. (14) . However, Husle et al. (15) found the male to female ratio increasing from 1.3 to 2.2. Ceylan et al. (16) has also reported higher prevalence of nasal polyposis in males as compared to females.

Lateralised middle turbinate
It is most the common complication following FESS and also the most common cause for revision endoscopic sinus surgery accounting from 35 -78 % (5,17) . In our study, the MT was lateralised in 14.7% patients in the Conchopexy suture group and 17.6% in the Bolgerization group, which was statistically insignificant.
This was higher than reported in the study by Hegazy et al. (18) .
It could be because we followed strict criteria to consider the middle turbinate as lateralised when the upper part of the MT was seen touching the lateral nasal wall irrespective of its extent even if the inferior part of the turbinate was medialised.
The overall outcome of the medialisation technique performed was also influenced by the technique and surgical skills of various surgeons. Postoperative infection, improper nasal douching, and structural memory of MT after out fracturing during FESS also contribute to middle turbinate lateralisation (4) .

Normal/medialised middle turbinate
In our study, more patients in Conchopexy suture had middle turbinate either in normal or medialised position than those of Bolgerization group. Hegazy et al. (18) in study of 39 patients, reported normal MT in all patients of Conchopexy suture group and 85% patients of Bolgerization group.

POSE score
Several scoring systems such as Lund Kennedy endoscopic score (LKES), modified LKES, discharge, inflammation and polyp/ oedema (DIP) score and POSE score are described in literature for endoscopic evaluation of polyp, oedema, discharge, crust and scarring in nose and paranasal sinuses (19)(20)(21) . POSE score (20) was used for our study as it provides a detail assessment of the status of the middle turbinate and sinuses. A total score of 40 was obtained by adding score of 20 from each side. Higher score denoted worse outcome. POSE score was recorded at 12th postoperative week to allow sufficient time for sinuses to heal and also allow the vicryl sutures to dissolve.

Middle meatus and maxillary antrum
Middle turbinate being close to osteomeatal complex interferes with mucociliary drainage and ventilation of the sinuses. In the study by Musy et al. (22) , middle meatal stenosis was found to be the cause for revision surgery in 39% of the cases. In our study, the maxillary antrum was normal in 61.7% of patients in In addition, comparing the outcome of one technique on one side and another technique on the other side in the same patient is also recommended as it avoids confounding factor that can affect the outcome when done in different patients.

Conclusions
Conchopexy suture and Bolgerization techniques were equally effective in preventing middle turbinate lateralisation.

Authorship contribution
UG and BP were involved in concept and design, drafting the manuscript, critical revision of the manuscript, RKM wrote the protocol, collected and analyzed data, drafted the manuscript.
All authors read and approved the final manuscript.