SYDNEY, AUSTRALIA--Resection of the middle turbinate during functional endonasal sinus surgery (FESS) remains a topic of debate. Some clinicians believe the anterior middle turbinate should be preserved; others contend that middle turbinate resection (MTR) is appropriate for selected patients. A new study of more than 1,000 patients suggests that partial MTR may be a useful adjunct to FESS for those with severe, chronic rhinosinusitis.[1]

In an interview with RESPIRATORY REVIEWS, lead author Thomas Havas, FRACS, noted that the bias in recent years has been in favor of preserving the middle turbinate. "There's been a kind of hierarchical pressure not to do the resection," said Dr. Havas, Chief of Otolaryngology and Head and Neck Surgery at the Prince of Wales Hospital in Sydney, Australia. "But I think the pendulum is starting to swing toward doing the resection; in five or 10 years, it might be viewed as a routine procedure."

IMPROVED OUTCOME

The study population consisted of 1,106 randomly divided patients, all of whom had persistent symptoms and radiologic evidence of severe rhinosinusitis. In 597 patients, the middle turbinate was preserved; the other 509 patients underwent partial MTR (only the anterior-inferior third of the turbinate was resected) during FESS.

Two significant differences in outcome were found. Persistent synechiae were detected in 51 (8.5%) of the patients with a preserved middle turbinate but in none of those who underwent MTR. Furthermore, only 36 (7.1%) of the MTR patients needed revision surgery, compared with 93 (15.6%) of those in the other group.

Not everyone benefited from MTR, however. When the researchers stratified patients by extent of initial disease, they found that the type of surgery made little difference in revision rates for patients with mild rhinosinusitis. Among patients with severe disease, though, MTR was clearly beneficial: Revision surgery was needed by only 12.4% of those who had undergone partial MTR but by 69% of those who had not. No adverse effect on smell was noted among the MTR patients; in fact, these patients experienced a slight benefit in olfactory acuity.

Three patients (two in the MTR group and one in the other group) experienced severe operative epistaxis. One MTR patient had an orbital hematoma.

No instances of chronic crusting, drying, or atrophic rhinitis were observed in the MTR group during follow-up (mean, 4.2 years; up to 10 years in some cases). However, because such changes may take more than seven years to develop, the researchers said that they are continuing to monitor the patients.

Because of their findings, Havas and Lowinger suggested that "surgeons should consider the inclusion of partial MTR … when performing FESS for patients in whom there is extensive mucosal disease or the potential for middle turbinate lateralization or scarring."

--Stanley Nelson

Reference
1. Havas TE, Lowinger DSG. Comparison of functional endonasal sinus surgery with and without partial middle turbinate resection. Ann Otol Rhinol Laryngol. 2000;109:634-640.