A Comparative Study on the Outcome of Endoscopic Sinus Surgery with and Without Partial Middle Turbinectomy

A COMPARATIVE STUDY ON THE OUTCOME OF ENDOSCOPIC SINUS SURGERY WITH AND WITHOUT PARTIAL MIDDLE TURBINECTOMY

Dissertation submitted to

The Tamil Nadu Dr.M.G.R. Medical University

Chennai

In partial fulfilment

Of the requirements for the award of

M.S.BRANCH IV

(OTORHINOLARYNGOLOGY)

MAY 2020

CERTIFICATE I

This is to certify that the dissertation entitled “A COMPARATIVE

STUDY ON THE OUTCOME OF ENDOSCOPIC SINUS SURGERY

WITH AND WITHOUT PARTIAL MIDDLE TURBINECTOMY” is a bonafide record of work done by Dr. ANSHA ELDHOSE in the Department of Otorhinolaryngology, Madurai medical college and Govt. Rajaji hospital,

Madurai in partial fulfilment of the requirements for the award of the degree of M.S. Branch IV (Otorhinolaryngology), under my guidance and supervision during the academic period 2017-20.

I have great pleasure in forwarding the dissertation to The Tamil

Nadu Dr. M.G.R. medical university.

Prof. Dr.K.VANITHA M.D, DCH Prof.Dr.N.Dhinakaran M.S. (ENT) The Dean, The professor and Head, Madurai Medical College and Department of ENT, Govt. Rajaji hospital, Madurai Medical College and Madurai. Govt. Rajaji hospital, Madurai.

CERTIFICATE - II

This is to certify that this dissertation work titled “A

COMPARTIVE STUDY ON THE OUTCOME OF ENDOSCOPIC

SINUS SURGERY WITH AND WITHOUT PARTIAL MIDDLE

TURBINECTOMY” of the candidate Dr.ANSHA ELDHOSE with registration Number 221714101 for the award of degree of M.S. Branch IV in the branch of Otorhinolaryngology.

I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis filecontains from introduction to conclusion pages and result shows 13 percentage of plagiarism in the dissertation.

Guide & Supervisor sign with

Seal.

DECLARATION

I, Dr. ANSHA ELDHOSE, solemnly declare that the dissertation entitled “A COMPARATIVE STUDY ON THE OUTCOME OF

ENDOSCOPIC SINUS SURGERY WITH AND WITHOUT PARTIAL

MIDDLE TURBINECTOMY” is a bonafide record of work done by me during the period of August 2018 – September 2019 at Madurai medical college and Govt. Rajaji hospital, Madurai.

This dissertation is submitted to the Tamil Nadu Dr. M.G.R.

Medical University for the examinations to be held in May 2020 in partial fulfilments of the requirements for the award of M.S. Branch IV

(Otorhinolaryngology). I have not submitted this dissertation work previously for the award of any degree or diploma from any other

University.

Date: /10/19

Place: Madurai Dr. ANSHA ELDHOSE

ACKNOWLEDGEMENTS

In days, when acknowledgements have become more of custom than thanks giving, I would like to dedicate this work to people who have helped me in completing this study.

At the outset, I would like to express my deepest gratitude to my guide Prof.Dr.N.Dhinakaran, Professor and Head, Department of

Otorhinolaryngology and head & neck surgery, Madurai medical college&

Govt. Rajaji hospital, Madurai, for allowing me to work under his knowledgeable supervision. His constant love, sincerity and dedication for the subject and for me cannot be compared. He was a source of strength from which I benefited a lot. His efforts in leading me achieve through my career so far can never be compensated.

I express my deep sense of gratitude and indebtedness to Prof. Dr.

Saravanamuthu, Prof.Dr.ArulSundaresh Kumar, Prof. Dr.Thangaraj,

Prof. Dr. Alaguvadivel, Dr. Radha Krishnan, Dr. Sivasubramanian, Dr.

Raja Ganesh, Dr. Venkateswaran, Dr. Muthu Kumar, Dr. Vinoth for their remarkable patience, understanding, unflinching guidance and

5 suggestions and above all kind words of encouragement that helped me to conduct this study with confidence and sense of purpose.

I would be failing in my duty if I do not thank the patients for their co

-operation and kind consent to use the knowledge gained from treating them.

As it is said “you always reserve the best for the last”. This acknowledgement will be meaningless if I don’t dedicate this work to my husband and parents for their eternal support and understanding of my goals and aspirations. Their infallible love and support has always been my strength. Their patience and sacrifice will remain my inspiration throughout my life.

Above all, I thank the Lord almighty for his kindness and benevolence.

ANSHA ELDHOSE

TABLE OF CONTENTS

Chapter TITLE Page No. No. 1 INTRODUCTION 1

2 AIM OF THE STUDY 4 3 REVIEW OF LITERATURE 5 3.1 ANATOMY OF NOSE 10 3.2 ANATOMY OF PARANASL SINUSES 26 3.3 PHYSIOLOGY OF PARANASL SINUSES 31 3.4 CHRONIC RHINOSINUSITIS 40

4 MATERIALS AND METHODS 45 5 OBSERVATION AND RESULTS 53

6 DISCUSSION 70

7 CONCLUSION 76 8 BIBLIOGRAPHY 77 PROFORMA

MASTER CHART ETHICAL CLEARANCE CERTIFICATE PLAGIARISM CERTIFICATES

LIST OF TABLES

S.No. CONTENT PAGE No. Table 3.1 Lund Mackay staging system: endoscopic staging 8 Table 3.2 Major and minor symptoms in rhinosinusitis 40 Table 4.1 Lund Mackay Endoscopic scoring system for 47 preoperative assessment Table 4.2 Lund Mackay Endoscopic scoring system for 51 post-operative assessment Table 5.1 Age distribution 54 Table 5.2 Gender distribution 55 Table 5.3 Chief complaints 56 Table 5.4 Preoperative DNE scores 58 Table 5.5 Comparison of DNE findings between two groups 60 at postop assessment at 1st week Table 5.6 Comparison of DNE findings between two groups 62 at postop assessment at 6th week Table 5.7 Comparison of DNE findings between two groups 64 at postop assessment 3rd month Table 5.8 Comparison of post-op symptomatic relief- Nasal 66 discharge Table 5.9 Comparison of post-op symptomatic relief- Nasal 68 obstruction

LIST OF FIGURES

S.No. CONTENT Page No. Figure 3.1 Muscles of external nose 11 Figure 3.2 Nasal bones 12 Figure 3.3 Cartilages of external nose 13 Figure 3.4 Nasal septum 15 Figure 3.5 Lateral wall of nose 16 Figure 3.6 Middle meatus 18 Figure 3.7 Patterns of superior attachment of uncinate process 19 Figure 3.8 Osteomeatal complex 22 Figure 3.9 Types of frontal cells 24 Figure 3.10 Keros classification 24 Figure 3.11 Location of paranasal sinuses 26 Figure 3.12 Mucociliary transportation in maxillary sinus 33 Figure 3.13 Mucociliary transportation in frontal sinus 34 Figure 4.1 Technique of partial middle turbinectomy 50 Figure 5.1 Age distribution 54 Figure 5.2 Gender distribution 55 Figure 5.3 Chief complaints 57 Figure 5.4.1 Preoperative DNE scores- Edema 59 Figure 5.4.2 Preoperative DNE scores- Discharge 59 Figure 5.5 Post- op DNE score- 1st week 61 Figure 5.6 Post- op DNE score- 6th week 63 Figure 5.7 Post- op DNE score- 3rd month 65 Figure 5.8 Comparison of post-op symptomatic relief- Nasal 67 discharge Figure 5.9 Comparison of post-op symptomatic relief- Nasal 69 obstruction

1. INTRODUCTION

Chronic rhino sinusitis is a common cause of morbidity affecting quality of life and ability to work effectively1.Its prevalence though it varies with age, gender and geographical location was found to be 15% in general population2.According to the National institute of allergy and infectious diseases ,it is estimated that 134 million Indians, i.e. about 12.5% of the population, suffer from chronic rhinosinusitis3.

On considering pathophysiology, a mucosal edema following viral or bacterial infection results in obstruction of drainage and ventilation of paranasal sinuses and with this the morphology of the lining mucosa of the nasal sinuses4.Now a day, sinus surgery is focused on specificexenteration of the tissue causing obstruction rather than old concept of removing all the diseased sinus mucosa5. One of the major aims of middle meatal endoscopic surgery is providing sufficient drainage and ventilation at the level of osteomeatal complex. When the ventilation is restored, the mucosa may regain near normal appearance and function. Anatomical abnormalities of middle turbinate like concha bullosa, paradoxical middle turbinate, double middle turbinate predisposes to sinusitis through the obliteration of osteomeatal complex. Even when the middle turbinate is anatomically normal, the anterior part of middle turbinate may exhibit mucosal hyperactivity, causing restrictions to sinus ventilation and drainage and also

10 normal middle turbinate may lateralize postoperatively results in reobstruction of osteomeatal complex affecting sinus drainage or ventilation. Adhesion or synechiae formation between the middle turbinate and lateral nasal wall is a common complication after endoscopic osteomeatal surgeries and it may lead to restenosis of the region and recurrent disease6,7.

There is a considerable controversy regarding the efficacy of middle turbinate resection in endoscopic sinus surgery. In functional endoscopic sinus surgery, middle turbinate is often preserved. However its presence may prevent good access to the middle meatus which will affect the surgical result. There is a general agreement that patients with anatomical abnormalities of middle turbinate like concha bullosa as well as paradoxical middle turbinate are candidates for resection.Because of the controversies, there is a lot of debate with regard to recommendations to proceed on normal middle turbinate. Opinions of those who oppose the middle turbinate resection are that middle turbinate is an important anatomic and physiologic structure and unnecessary resection will lead to loss of landmark for future surgeries5,8,9. And opinions of those who favour resection of turbinate are that it will cause improved visualization and decreases the chance of turbinate lateralization;thereby prevent formation of synechiae and stenosis of the antrostomy10,11,12.

So this study was undertaken to assess the efficacy of partial middle turbinate resection in patients with chronic rhino sinusitis and specifically regarding any effect on symptomatic relief and post-operative healing.

2. AIM OF THE STUDY

1) To compare and study the outcome of endoscopic sinus surgery with and without partial middle turbinate resection.

2) To confirm the significance of middle turbinate intervention as one of the most important steps for endoscopic sinus surgery.

3. REVIEW OF LITERATURE

Chronic rhino sinusitis is a multifactorial disease leading to inflammation and infection of nose and Para nasal sinus mucosa. Though its mortality is low, due to its high morbidity, extensive studies are done for understanding the pathophysiology of the disease process. Complex interplay of host and environmental factors including anatomical and genetic predisposition of the individual have been found to affect the chronicity of the condition13.

The management and diagnostic modalities of Sino nasal pathologies have undergone a drastic change in the past two decades with the advent of nasal endoscopes. Nasal endoscopy was first performed by Hirschman in

1903 using a modified Nitzecystoscopy which he used in the nasal cavity and in the maxillary sinus via a tooth socket14. In 1922, Spielberg, was the first to introduce an endoscope into the maxillary sinus via the inferior meatus15. In 1925, Maltzused the term sinuscopy and described techniques for endoscopically examining the maxillary sinuses via both inferior meatal and canine fossa routes16. These endoscopes using a series of small lenses continued in use until HH Hopkins, Professor of Optic invented a far superior system in 1950s based on solid glass rod, which is now universally in use17.

Pioneering studies of Messerklinger, in early 1950s and 1960s on the mucociliary clearance pathways in Para nasal sinuses obtained vital information regarding the pathophysiology of chronic rhino sinusitis. From endoscopic studies on fresh cadaver heads and simultaneously during sinus operations he observed that mucus produced in the Para nasal sinuses follow definite pathways towards their respective ostia. Factors impeding or blocking these natural pathways have found to play important role in the development of Para nasal sinus pathology. He proposed that in recurring or persisting sinus infections, the focus of infection usually lies in the stenotic areas of ethmoidal infundibulum or the frontal recess and clearing the disease in this area will help in reestablishment of ventilation and drainage via physiologic routes18.

Zinreich et al (1987) stated that CT and nasal endoscopy are complementary in the diagnosis and treatment of nasal and paranasal sinus diseases19. According to GittaMadani et al, recurrent sinonasal inflammatory conditions not responding to medical line of management require computed tomography scanning of paranasal sinuses20.

Chronic rhino sinusitis not responding to medical management will require surgical intervention and functional endoscopic sinus surgery

(FESS) is now accepted as the surgical management of choice in chronic sinusitis. This philosophy of opening the natural ostium of the diseased

15 sinus was popularized by Stammberger21 and Kennedy22. Dua K et al. stated that removal of disease in osteomeatal complex region is the basic principle of FESS23.Stammberger and Wolf proposed that functional endoscopic sinus surgery will provide better results in chronic sinonasal diseases24.According to Palmer J N and Kennedy D W, FESS has a high rate of success ranging from 75% to 95% improvement of symptoms in patients who have medically refractory chronic rhinosinusitis25. Soler Z M et al in their study on symptom based outcomes after endoscopic sinus surgery in patients with chronic rhino sinusitis, found that surgical results showed statistically and clinically significant improvement in symptoms26. Smith T L et al from their prospective study on 119 patients with chronic rhino sinusitis who underwent FESS, after follow up for more than a year, concludes that surgical management of chronic rhino sinusitis is associated with significant improvement on objective and quality of life27.

The Lund and Mackay staging system for chronic rhino sinusitis is a simplified approach which produces numerical score for four aspects of the condition and this has been used in a number of outcome studies in chronic rhinosinusitis28-30. A multicentre prospective study on 1840 patients undergoing surgery for chronic rhino sinusitis done by Hopkins C et al showed that The Lund-Mackay score correlates well with other markers of disease severity, the nature of surgery offered, and its outcome31.Oluwole et

16 al32 compared the systems proposed by Jorgensen33, May and Levine34,

Lund- Mackay and Newman et al35 and demonstrated that the Lund-

Mackay system facilitated the highest level of both interobserver and intraobserver agreement.

Table 3.1 Lund Mackey endoscopic staging system

The Lund Mackay staging system : endoscopic staging

LEFT RIGHT

Polyp (0/1/2/3)

Edema (0/1/2)

Discharge (0/1/2)

Crusting(0/1/2)

Scarring (0/1/2)

Total points

For polyp, 0-absence of polyp, 1-middle meatal polyp, 2-polyp beyond middle meatus, but not completely obstructing the nose, 3-polyps completely obstructing the nose

For edema, 0- absent, 1-mild, 2-severe

For discharge, 0-no discharge, 1-clear thin discharge, 2-thick purulent discharge

For crusting,0-absent, 1-mild, 2-severe

For scarring,0-absent, 1-mild, 2-severe

A score of 1 or above is considered abnormal

3.1 ANATOMY OF NOSE

EXTERNAL NOSE

VESTIBULE

The vestibule is the skin lined area of nose from the external nares into the nasal fossae, upto the limen nasi, at the superior margin of the lower lateral cartilage. It consists of coarse hairs or vibrissae, sebaceous glands and sweat glands36.

MUSCLES OF THE EXTERNAL NOSE

The nose has a number of muscles and is supplied by branches of the facial nerve. The depressor septin`asi muscle helps in depressing the septum and tip and expanding the external nares during forced inspiration. It attaches between the alveolus and the medial crus of the lower lateral cartilage. The nasalis muscle has an alar and a transverse part. Its contraction produces shortening and dilatation of the nostril. The procerus muscle (depressor glabellae) is a continuation of frontalis. It helps in shortening the nose and facial movement of the area between the eyebrows. Levator labii superioris alaequae nasi arises from the frontal process of the maxilla and blends with the perichondrium of the lateral crus of the lower lateral cartilage. It dilates the upper lip.

The external nasal framework is composed of bony and cartilaginous components. The bony skeleton is formed by the nasal bones, frontal processes of the maxillae and nasal part of the frontal bone. Cartilaginous part include septum, upper and lower lateral cartilages and a variable number of minor accessory alar cartilages36.

Figure 3.1 Muscles of external nose

NASAL BONES

The nasal bones are two in number, wedge-shaped, usually convex and smooth on its outer surface and concave and rough internally. They unite with each other in the midline, superiorly with the frontal bone at the nasofrontal suture and laterally with the frontal process of the maxilla at the nasolacrimal suture. The nasal spine of frontal bone and the perpendicular plate of ethmoid support the nasal bones36.

Figure 3.2 Nasal bones

CARTILAGES

The nasal cartilages are composed of hyaline cartilage. The upper lateral cartilages lie inferior to the nasal bones and the lower lateral cartilages (alar cartilages) form the lower third of the nose. The groove between the upper and lower lateral cartilages is known as the limen nasi. The medial aspect of the upper lateral cartilages are continuous with the nasal septal cartilage. The lower lateral cartilages are each composed of a medial and lateral crus which meet at the dome of the tip. One to four minor sesamoid cartilages are found between the upper and lower lateral cartilages.

The part of the septum running between the tip of the nose and philtrum is called the columella. The medial crura of lower lateral cartilages are loosely attached to each other in the midline and contribute to the columella which bounds the anterior nares medially36.

Figure 3.3 Cartilages of external nose

NASAL CAVITY

The nasal cavity extends from the external nares or nostrils to the posterior choanae. Posteriorly it is narrower and becomes continuous with the nasopharynx. Vertically, it extends from the palate to the cribiform plate and superiorly it narrows to the olfactory cleft. The nasal cavity is divided into two by a septum. Each half has a floor, a roof, a lateral wall and a medial (septal) wall. The highest part of the nasal cavity is related to the cribriform plate of the ethmoid and this area is covered by olfactory epithelium. Respiratory mucous membrane lines the rest of nasal cavity (with the exception of the nasal vestibule), and is continuous with that of the paranasal sinuses, nasolacrimal duct and nasopharynx36.

NASAL SEPTUM

The nasal septum is composed of membranous portion, cartilage and bony portion. The cartilaginous portion is composed mainly of the quadrilateral cartilage with contribution from the lower and upper lateral alar cartilages forming the anterior nasal septum. The upper margin of the cartilage is connected to the upper lateral cartilages, forming the anterior septal angle. Collagenous fibres to the nasal bones, perpendicular plate of the ethmoid and vomer and inferiorly in the nasal crest of the palatine process of the maxilla keeps the septal cartilage in position. The perpendicular plate of ethmoid forms the superior and anterior bony septum and is continuous above with the cribriform plate and crista galli. The vomer forms the posterior and inferior nasal septum and articulates with the rostrum of the sphenoid. The inferior border of the vomer articulates with the nasal crest formed by the maxillae and palatine bones. The anterior border articulates with the perpendicular plate above and the quadrilateral cartilage inferiorly. The posterior edge of the vomer forms the posterior free edge of the septum36.

Figure 3.4 Nasal septum

THE LATERAL NASAL WALL

Anteriorly in the lateral wall is the vestibule and just behind this is a plain structure less area lined by nasal mucosa called atrium. Behind the atrium are the three scrolls of the inferior, middle and superior turbinates overlying the respective meati. Sometimes a supreme turbinate will also be present36.

Figure 3.5 lateral wall of nose

INFERIOR MEATUS

The inferior meatus lies just lateral to the inferior turbinate and it extends almost the entire length of the nasal cavity. The nasolacrimal duct opens into the inferior meatus usually just anterior to its highest point (at the junction of the anterior and middle third)36.

INFERIOR TURBINATE

The inferior concha is a separate bone to which the mucoperiosteum is firmly attached. The maxillary process of inferior concha articulates with the inferior margin of the maxillary hiatus. It also articulates with the ethmoid, palatine and lacrimal bone. The turbinate has submucosal cavernous plexus with large sinusoids under autonomic control which provides helps in nasal resistance36.

MIDDLE TURBINATE

The middle turbinate is a convoluted structure and has three parts depending on its attachment. The mean height of the middle turbinate is

14.5 mm anteriorly and 7 mm posteriorly and its mean length is 40 mm37.

The anterior one third is in the sagittal plane and is attached to the cribriform plate. It also has a small attachment to the front nasal process of maxilla. The middle one third lies in the coronal plane attached to lamina papyracea. This part of middle turbinate is called the ground lamella or the basal lamella and it separates anterior ethmoidal cells from the posterior ethmoidal cells. The posterior third lies in the horizontal plane and is attached to the lamina papyracea and perpendicular plate of palatine bone36.

MIDDLE MEATUS

The middle meatus lies lateral to the middle turbinate. It receives drainage from the frontal, maxillary and anterior ethmoidal sinuses.

Middle meatus possess complex anatomies which include the following structures36.

Figure 3.6 Middle meatus

Uncinate process

In the middle meatus, most anteriorly is a curved ridge called the uncinate process. It is sickle shaped and has a vertical and horizontal limb with an intermediate transitional part. The lower part of uncinate articulates anteriorly with the lacrimal bone and posteriorly with the inferior turbinate and perpendicular plate of palatine bone. The upper end of uncinate process may show different patterns of attachment38.

Type 1 uncinate : the commonest type where the uncinate process attaches laterally to lamina papyracea. In such cases the upper end of uncinate encloses within it a blind recess called the recesses terminalis. The commonest mode of drainage of frontal sinus is medial to uncinate process.

Type 2 uncinate : the uncinate process may attach to the skull base. Here frontal sinus drains into the infundibulum.

Type 3 uncinate : the upper most portion of the uncinate may bend medially to attach to middle turbinate.

Occasionally the upper end of uncinate process lies free in the middle meatus. Also in some cases the uppermost portion of uncinate can get pneumatised and compromise the infundibulum.

Figure 3.7 Patterns of superior attachment of uncinate process

Ethmoidal bulla

Behind the uncinate is the well pneumatised anterior ethmoidal cell, the ethmoidal bulla. It occasionally does not extend up to the base of skull and is separated by a recess called the suprabullar recess. It is separated posteriorly from the ground lamella by retrobullar recess. These two

28 recesses together form a semilunar space above and behind the bulla called the sinus lateralis of Grunwald. This sinus opens into the middle meatus by a semilunar cleft called the hiatus semilunaris superioris.

The boundaries of sinus lateralis are

Roof :ethmoid fovea

Floor :ethmoidal bulla

Posteriorly : ground lamella of middle turbinate

Anteriorly : opens into frontal recess36

Hiatus semilunaris inferioris

This sickle-shaped, two-dimensional structure lies between the free concave posterior margin of the uncinate process and the convex anterior surface of the ethmoidal bulla. This cleft leads to a three-dimensional space, the ethmoidal infundibulum36.

Ethmoidal infundibulum

The medial wall of the ethmoidal infundibulum is provided by the entire extent of the uncinate process and its mucosal covering. The major part of the lateral wall of the ethmoidal infundibulum is provided by the lamina papyracea of the orbit, with the frontal process of the maxilla and rarely, the lacrimal bone providing the remainder anterior and superiorly.

The posterior border of the ethmoidal infundibulum is composed largely of the anterior surface of the ethmoidal bulla, in front of which the infundibulum opens into the middle meatus through the inferior hiatus semilunaris. Superiorly, configuration of the ethmoidal infundibulum depends on the attachment of uncinate process: if this turns laterally thus attaching to the orbit, the ethmoidal infundibulum ends in a superior blind alley, the terminal recess (recessusterminalis) and the frontal recess will have a median drainage. If the uncinate process reaches the skull base superiorly or turns medially to attach to the middle turbinate, the ethmoidal infundibulum is contiguous with the frontal recess superiorly and the frontal sinus will have a lateral drainage. The maxillary sinus ostium is located in the medial wall of the ethmoidal infundibulum, at the transition of its middle to posterior third36.

OSTEOMEATAL UNIT

The osteomeatal unit is the common drainage pathway of the anterior paranasal sinuses. It controls and modulates the mucociliary drainage of the frontal sinuses, anterior ethmoid cells and maxillary sinus. This is composed of the following structures: uncinate process, ethmoid bulla, middle turbinate, and the spaces between these structures (infundibulum, middle meatus and semilunar hiatus)36.

Figure 3.8 Osteomeatal complex

Frontal recess

It is in the most anterosuperior portion of the middle meatus. The natural ostium of the frontal sinus most frequently presents as an hourglass narrowing opening directly into the recess. The frontal recess is bounded by:

Anteriorly : anterior wall of aggernasi cell

Posteriorly : Bulla ethmoidalis

Medially : middle turbinate

Laterally : lamina papyracea

Superiorly : fovea ethmoidalis

Inferiorly : dependent upon the attachment of the uncinate process36

The anterior ethmoidal cells may migrate antero superiorly into the frontal recess to produce different types of frontal cells namely39

Type 1 – Single cell above the aggernasi cell.

Type 2 – Two or more cells above the aggernasi cell.

Type 3 – Ethmoidal air cell that pneumatise cephalad into the frontal sinus through the frontal ostium but without extending 50% of vertical height of frontal sinus.

Type 4 – An isolated loner cell separately within the frontal sinus.

Frontal bulla cells – the cell that originate in the suprabullar region but pneumatise along the skull base into the frontal sinus along the posterior wall of frontal sinus.

Suprabullar cells – Cells above the bulla ethmoidalis that do not enter the frontal sinus.

Figure 3.9 Types of frontal cells

ROOF OF ANTERIOR ETHMOID COMPLEX

The olfactory fossa forms the roof of ethmoid. It is formed by the horizontal lamella of the cribriform plate, its vertical lamellae and a part of the orbital plate of frontal bone. The depth of the olfactory fossa varies and is classified by Keros as36

Type 1 : 1 – 3 mm

Type 2 : 4 – 7 mm

Type 3 : 8 – 17 mm

Figure 3.10 Keros classification

SUPERIOR MEATUS

The posterior ethmoidal cells open into this region. A supreme turbinate is present above the superior meatus in 60 - 67 percent of patients36.

POSTERIOR ETHMOID COMPLEX

The ground lamella of the middle turbinate is the border between anterior and posterior ethmoidal sinuses. All clefts and cells opening posterior to the basal lamella belong to the posterior ethmoid in the superior meatus. The sphenoid sinus ostium opens into the sphenoethmoidal recess medial to the superior turbinate. The posterior most ethmoid cells can develop laterally and even superiorly to the sphenoid sinus. In these cases, the optic nerve and even internal carotid artery may bulge into these sphenoethmoidal cells36.

SPHENOETHMOIDAL RECESS

The sphenoethmoidal recess lies medial to the superior turbinate and is the location of the ostium of the sphenoid sinus36.

3.2 ANATOMY OF PARANASAL SINUSES

Figure 3.11 Location of paranasal sinuses

MAXILLARY SINUS (Antrum of Highmore):

These paired sinuses lie under the cheek. It is the largest of the group of paranasal sinuses. The capacity of the maxillary sinus is approximately

15 ml. It is more or less shaped like a pyramid. Its boundaries are

Base (medial wall): The base of the pyramid corresponds to the lateral nasal wall. This wall has its convexity facing the sinus. The central portion of the base is very thin, and in some areas could even be membranous. The natural ostium of the sinus is present in this wall.

Anterior wall: is covered by the periosteum, soft tissue and skin of the cheek. This wall has an opening called infraorbital foramen, which is situated about 1 cm below the infraorbital margin. Infraorbital nerve and vessels emerge through this foramen.

Posterior wall: is formed by a thin plate of bone and is related to pterygopalatine fossa containing third part of internal maxillary artery, vidian nerve and the sphenopalatine ganglion. Sphenopalatine foramen is present posteromedially in this wall which transmits sphenopalatine vessels and nerves.

Roof: of the sinus is formed by a thin orbital plate and it is traversed by a groove containing the infraorbital vessels and nerves.

Floor: is formed by alveolar and palatine process of the maxilla. The root of molars and second premolar reach up to the floor of the maxillary sinus, separated by a thin lamella of bone. Dental infections from these teeth may involve the maxillary sinus through this thin lamella of bone.

The maxillary sinus has biphasic growth. The first phase of growth occurs during the first 3 years of life while the second phase occur between

7 - 18 years36.

FRONTAL SINUS

The frontal bone is pneumatized to a variable degree and its shape and size also vary from person to person. The sinus is usually L shaped, composed of a horizontal and a vertical compartment. Posterior wall corresponds to the anterior wall of the anterior cranial fossa and floor is formed by the upper part of the orbits. An intersinus septum is usually present, but may be paramedian and is partially dehiscent in some. Frontal sinus appear very late in life by 6-7 yrs of age. The sinus drains into the anterior part of the middle meatus through the fronto nasal duct36.

ETHMOID SINUS

It is situated in the anterior skull base. It is made up of complex bony labyrinth of thin walled cells. A few ethmoid cells may be present at birth.

In adults 6 - 10 ethmoid cells may be present. Its boundaries are:

Lateral wall: is formed by the orbital plate of the ethmoid otherwise known as the lamina papyracea. This is a thin lamina of bone separating the orbit from the ethmoidal air cells. Infections involving the ethmoid air cells may spread to the orbit through this wall.

Roof: is formed by the frontal bone anteriorly and by the face of sphenoid and orbital process of palatine bone posteriorly.

The ethmoidal cells increase in size from above downwards, and from before backwards. The cells of the ethmoid sinus are divided into two

37 groups, the anterior and posterior group. The anterior ethmoidal cells drain into the infundibulum of the middle meatus while the posterior ethmoid cells drain into the superior meatus36.

SPHENOID SINUS

The sphenoid consists of a body (pneumatized to a variable degree), greater and lesser wings and lateral and medial pterygoid plates. In the anterior face of the body on either side ostia of the sinuses open into the sphenoethmoidal recess. The sinus cavities are variable in size and shape.

Pneumatization can extend into the greater wing, pterygoid processes and rostrum and may encroach on the basilar part of the occipital bone.

Depending on pneumatisation four general forms are described

1. Conchal: with only a rudimentary sinus (2-3 percent) .

2. Presellar :pneumatized as far as the anterior bony wall of the pituitary

fossa(11 percent).

3. Sellar :pneumatization extends back beneath the pituitary fossa (59

percent) .

4. Mixed (27 percent).

The sphenoid sinus is divided by a septum which is often paramedian, and there may be diverticula and incomplete septa. The inferior surface of the optic nerve and internal carotid artery pass close to these sinuses and often produce variable prominences in the lateral and posterior walls of the

38 sinus36.According to DeLano et al (1996) the relations of the optic nerve to sphenoid and ethmoid sinuses were classified as40

- Type 1:the nerve does not contact or impinge on either the sphenoid

or posterior ethmoid cells

- Type 2: the nerve indents the sphenoid sinus, without contacting the

posterior ethmoid cells

- Type 3: the nerve runs through the sphenoid sinus, and it is

surrounded by the pneumatised sinus for atleast 50%

- Type 4: the nerve courses close to both the sphenoid and posterior

ethmoid sinus.

3.3 PHYSIOLOGY OF PARANASAL SINUSES

The normal function of the paranasal sinuses and their lining mucous membranes depends primarily on two important factors: ventilation & drainage. The ventilation of the sinuses requires a patent sinus ostium and a patent pathway connecting the ostium to the nasal cavity (prechamber).

Normal drainage of the sinuses is a complex function of both mucous secretion and the ciliary mechanisms that transport the mucus through and out of the sinus and into the nasal cavity. The secretions from the sinuses normally form a continuous sheet called mucous blanket over the nasal mucosa. The mucous blanket is made of mucus layer (gel phase) above and a serous layer (sol phase) below, floating over cilia, which are constantly beating towards the nasopharynx. This is called the mucociliary transportation mechanism.

An unimpeded flow of air during inspiration through the nose is also important in the transportation of mucus, because the suction or negative pressure created promotes the transportation of mucus out of the sinuses.

Messerklinger’s studies revealed that the mucus produced in the sinuses follow definite pathways and even if these pathways may be impeded or blocked by various pathologic conditions, their direction is not significantly altered41.

Mucus transportation pathways in maxillary sinus

In the maxillary sinus, mucus transportation starts from the floor of the sinus in a stellate pattern. It is transported along the anterior, medial, posterior, lateral walls of the sinuses and along the roof to the natural ostium of the maxillary sinus. The maxillary sinus ostium opens into the floor of the posterior third of the ethmoidal infundibulum, which is bordered by the uncinate process medially and the lamina papyracea of the orbit laterally.

The mucus from the maxillary sinus is transported via the infundibulum to the hiatus semilunaris. After leaving the hiatus semilunaris, the mucus is then transported over the medial face of the inferior turbinate posteriorly into the nasopharynx.

Secretions from the maxillary sinus are always transported via the natural ostium, even when one or more accessory ostia are present and even in those patients in whom a patent window in the inferior meatus has been surgically created (inferior meatalantrostomy)41.

Figure 3.12 Mucociliary transportation in maxillary sinus

Mucus transportation pathway in frontal sinus

The frontal sinus is the only sinus in which there is active inwardly directed transportation of mucus. Mucus is transported into the frontal sinus along the interfrontal septum and then laterally along its roof. From the roof mucus comes medially via the floor and the inferior portions of the posterior and anterior walls of the sinus. The mucus then exits the frontal sinus ostium with some amount getting recycled in the sinus several times.

Once the mucus has passed out of the frontal sinus ostium, it is transported through a narrow cleft, the frontal recess. This recess drains either directly into the ethmoidal infundibulum from above or medially to the ethmoidal infundibulum when the infundibulum ends with a superior

42 blind pouch. The frontal recess, depending on anatomical variations, may also collect secretions from other ethmoidal compartments, including secretions from the lateral sinus, from the aggernasi, from a pneumatised middle turbinate and from the most anterior ethmoidal cells. Eventually the secretions from the frontal sinus merge with the secretions from the maxillary sinus and together they are transported back into the nasopharynx41.

Figure 3.13 Mucociliary transportation in frontal sinus

Mucous transportation pathways from anterior and posterior ethmoidal and sphenoidalsinuses

In ethmoidal air cells with the ostium located in its floor, the mucus is usually transported directly towards the ostium. If, however, the ostium is located higher in one of the walls, there is usually a spiral transportation pattern directed towards the ostium.

The border between the anterior & posterior ethmoidal sinuses is the ground lamella of the middle turbinate. All cells opening anteroinferiorly to the ground lamella are anterior ethmoidal cells and they drain into the middle meatus. All air cells that open posterosuperiorly to the ground lamella are posterior ethmoid cells and they drain via the superior meatus into the sphenoethmoidal recess. When there is a supreme, or fourth, turbinate with cells in the supreme meatus, these cells also drain into the sphenoethmoidal recess.

In the sphenoidal sinus, depending on the location of the ostium, there usually is spiral transportation of mucus toward the ostium, passing subsequently into the spenoethmoidal recess41.

Mucus transportation pathways along lateral nasal wall

Two major routes of mucociliary transportation are usually seen in the lateral nasal wall. The first route combines the secretions from the frontal and maxillary sinuses and the anterior ethmoidal complex. The secretions from these sinuses usually join in or near the ethmoidal infundibulum, and from there are transported over the free rear margin of the uncinate process and along the medial surface of the inferior turbinate towards the nasopharynx. Here the secretions pass anteriorly and inferiorly to the eustachian tube orifice. Active transportation continues up to the

44 borderline of the ciliated & the squamous epithelium in the nasopharynx.

From there the secretions are moved by gravity, and are assisted ultimately by the swallowing mechanism.

The second major route combines the secretions from the posterior ethmoidal cells and from the sphenoidal sinus. The secretions from these two sinuses join in the sphenoethmoidal recess and then are transported towards the nasopharynx posteriorly and superiorly to the eustachian tube orifice. The eustachian tube is thus situated like a breakwater between these two secretion pathways. The secretions from the nasal septum are transported more or less vertically downward to the floor of the nose and then backward, where in most cases they join the first secretion pathway to pass anteriorly and inferiorly to the eustachian tube41.

Effects of disease on mucus transportation

The normal transportation of mucus from the sinuses can be adversely affected by various disease processes.

If the composition of the mucus is altered so that the mucus produced becomes more viscous, the rate of transport toward the ostium will slow down and the gel layer becomes thicker. The thick secretions won’t be able to pass through the ostium and will get retained in the sinus for a variable period.

When there is a lack of mucus secretion or a loss of humidity at the mucosal surface the mucus becomes more viscous and the sol phase may become extremely thin and the gel phase will come into constant contact with the cilia, thereby impeding their action.

In cases of bacterial or viral super infection, not only may the mucosal glands be infected, but the entire mucosal surface may be partially destroyed or paralyzed and thus unable to carry out its mucociliary clearance function. A variety of ciliary or mucosal dysfunctions or malfunctions, such as immotile cilia syndrome and cystic fibrosis can also severely impair mucociliary clearance41.

Role of ethmoidal prechambers in ventilation and drainage of frontal and maxillary sinuses

The frontal and maxillary sinuses communicate with the middle meatus via very narrow and delicate clefts, or prechambers. The frontal sinus ostium opens into a funnel-shaped cleft, the frontal recess, also called the nasofrontal duct. The maxillary sinus ostium opens into a cleft in the lateral nasal wall, the ethmoidal infundibulum.

Both these clefts (prechambers) are part of the anterior ethmoid and have an important role in the ventilation and drainage of these sinuses. If in these clefts the opposing mucosal surfaces come into intense contact and firmly presses against each other as a result of mucosal swelling, this

46 pressure may seriously interfere with the drainage and ventilation of the larger dependant sinuses because the ciliary beat is immobilized and consequently the mucus is no longer transported away.

In blockage of sinuses, because of poor ventilation, the pH of the involved sinus will fall and this will in turn slow ciliary movement and cause mucus of a higher viscosity to be produced. The hypoxia and the retained mucus provide ideal conditions for the growth of pathogens.

Infection and toxins may additionally impair mucosal function, setting up a vicious cycle.

Any pathology like infection, allergy, trauma, tumor or anatomic variation that blocks the entrance into the middle meatus, the hiatus semilunaris, or the infundibulum may predispose to or promote partial or complete blockage of the maxillary or frontal sinus ostia41.

Spread of infection into frontal and maxillary sinuses

In the frontal sinus, mucus is actively transported into the sinus along the interfrontal septum on both sides. Apart from being inhaled into the sinuses, pathogens are deposited by the airflow at the entrance to the middle meatus, where they adhere to the mucous blanket. Because of the confluence of the secretion pathways from the entrance to the middle meatus with the pathways of the infundibulum and the frontal recess, these pathogens may be transported into the frontal sinus, where conditions are

47 ideal for growth. If the self-healing capacity of the sinus mucosa or medical treatment is insufficient to clear the sinus, acute or chronic recurring frontal sinusitis will develop.

The mucus in the maxillary sinus is transported upward along the natural pathways inside the sinus toward the maxillary sinus ostium, from which it exits the sinus. In some cases these thick secretions can re-enter the maxillary sinus through an accessory ostium and the mucus may continue to circulate. When the natural ostium is patent, this is not of much significance, but if the natural maxillary ostium is blocked by disease or when nasal infection is present, this inwardly directed route of transportation through an accessory ostium is one way by which pathogens may be transported into the maxillary sinus from the nose. As the natural ostium is blocked, these infected secretions cannot leave the sinus and maxillary sinusitis may result.

In many cases, when the patient attempts to blow the nose harder, infected secretions may be forced back into the maxillary sinus from the ethmoidal prechambers.

Most of the inflammatory diseases of the frontal & maxillary sinuses are rhinogenic, caused by infection within the nasal cavity and the anterior ethmoidal sinus41.

3.4 CHRONIC RHINOSINUSITIS

Rhinosinusitis is a spectrum of inflammatory and infectious diseases affecting the mucous membranes of the nose and paranasal sinuses. The sinus inflammation is mostly preceded by rhinitis and rarely occurs without concurrent nasal airway inflammation. Hence the term rhinosinusits is used instead of sinusits nowadays. When rhinosinusitis presents persistently for 3 months or more it is called chronic rhinosinusitis. The various symptoms and signs of rhinosinusitis are classified by the Rhinosinusitis Task Force of the American Academy of Otolaryngology- Head and Neck Surgery29.

Presence of two major symptoms or one major and two minor indicates rhinosinusitis

Major Symptoms Minor Symptoms

Facial pain / pressure Headache

Facial congestion / fullness Fever (nonacute)

Nasal obstruction / blockage Halitosis

Nasal discharge / purulence / Fatigue discoloured posterior drainage

Hyposmia / anosmia Dental pain

Purulence on nasal examination Cough

Fever (acute rhinosinusitis only) Ear pain / pressure / fullness

Table 3.2 Major and minor symptoms in rhinosinusitis

PATHOPHYSIOLOGY

Acute rhino sinusitis mostly develops in conjunction with an acute viral upper respiratory tract infection. The infection causes mucosal swelling leading to obstruction of the sinus ostia. A reduction in oxygen tension occurs which causes impairment of mucociliary transport resulting in transudation of fluid into the sinuses. Due to inflammation the mucous becomes more viscous and ciliary beat frequency alters. These changes will cause stasis of mucus and bacterial infection can ensue. Antigen-antibody reactions lead to release of histamine and other inflammatory mediators which cause changes in vascular permeability, destabilization of lysosomal membranes and other reactions. It will further result in inflammation, mucosal swelling and obstruction of sinus ostia. Many cells and proteins that are involved with inflammatory response like neutrophils, mast cells, T and B cells, immunoglobulins, interleukins, tumour necrosis factor, major basic protein, etc have a particularly major role in chronic rhinoinusitis. On histopathological examination, such cases show presence of a proliferative process with lymphocytes, plasma cells and eosinophils. In most cases, an eosinophilic infiltration may be seen either in the mucosa or in the sinus cavities themselves, with or without fibrosis of the lamina propria.

Chronic rhinosinusitis is an inflammatory disease, and it may or may not involve pathogenic microbes. The most common organisms identified

50 are Staphylococcus species (55%),Enterobacteriaceae organisms, anaerobes,

Gram-negative bacteria and fungi13.

DIAGNOSTIC TECHNIQUES

Clinical examination

Anterior rhinoscopic examination gives valuable information regarding condition of the turbinate, nasal mucosa and any mechanical obstruction as well as the quantity, quality, colour and viscosity of secretion.

Endoscopic examination

Diagnostic nasal endoscopy gives valuable information regarding nasal anatomy and drainage of sinuses. It also helps in evaluation of treatment response.

Radiological examination

Plain radiography

Occipitomental (Waters) view – The maxillary, frontal and the sphenoid sinus can be well assessed in this view. The ethmoid cells will get largely obscured. Mucosal thickening and air fluid levels can be seen.

Occipitofrontal (Caldwell) view – the frontal sinus, floor of the sellatursica and the crista galli can be better assessed by this view.

Lateral view - The degree of pneumatisation of the frontal and sphenoid sinus can be assessed in this view.

Computed tomography

CT scan of paranasal sinuses is the most preferred radiological modality to assess the sinuses. Axial and coronal sections of 5 mm thickness with 1 mm sections at the osteomeatal complex region are taken. It gives information regarding condition of paranasal sinuses, any anatomical variations and osteomeatal complex. It also acts as a road map for endoscopic sinus surgery13.

TREATMENT

Medical

Medical line of management is initially tried to reduce the symptoms and signs and also to prevent disease progression. Avoidance of allergen is the most important factor. Regular nasal douching can be done to improve nasal symptoms. Topical and systemic corticosteroids and nasal decongestants can also be tried. Low dose long term antibiotic therapy with macrolides can be tried in patients not responding to other medications.

Surgical

Functional endoscopic sinus surgery (FESS) is the surgical intervention of choice in chronic rhinosinusitis not responding to medical line of management. FESS restores sinus drainage and ventilation ultimately improving the sinus mucociliary function13.

4. MATERIALS AND METHODS

4.1 STUDY DESIGN : Prospective cohort clinical study

4.2 STUDY SETTING : Department of ENT, Government Rajaji Hospital

& Madurai Medical College, Madurai

4.3 STUDY SUBJECTS :

Inclusion criteria

1.Patients with chronic rhinosinusitis presented with clinical as well as radiological evidence of sinusitis and not responding to medical treatment(>3 months)

2.Age of the patients between 18-50 years

3.Both sexes

Exclusion criteria

1. Patients with concha bullosa, paradoxical middle turbinate and double

middle turbinate

2. Patients with acute inflammatory sinonasal disease

3. Patients with allergic bilateral sinonasal polyposis

4. Patients with any previous sinonasal surgery

5. Immuno compromised patients

6. Patients with autoimmune diseases and uncontrolled systemic

diseases

4.4 STUDY PERIOD :August 2018 to September 2019

4.5 SAMPLE SIZE

50 patients

4.6 TOOLS AND TECHNIQUES :

1. CASE DEFINITION- Patients with symptoms of sinusitis for more

than 3 months not getting relieved with medical line of management

with radiological evidence and requiring surgical intervention

2. A semi structured proforma with patient details, presenting

symptoms, ENT examination findings, diagnostic nasal endoscopy

findings, CT scan findings

3. The Lund and Mackey endoscopic staging system for staging of

chronic rhinosinusitis

4.7 METHOD OF STUDY:

The study is conducted on 50 patients presenting with signs and symptoms of chronic rhino sinusitis satisfying the inclusion and exclusion

55 criteria attending ENT OPD in Government Rajaji Hospital, Madurai.

Approval of the institutional ethical committee obtained .Patients was randomly taken as CASE (GROUP 1) and CONTROL (GROUP 2). After taking detailed history and clinical examination, computed tomography

(plain study) images of paranasal sinuses are taken.

Preoperative evaluation by

 Diagnostic nasal endoscopic examination

The severity of sinusitis is scored according to Lund-Mackay

endoscopic staging system.

Table 4.1 Lund and Mackay Endoscopic Scoring System for

preoperative assessment

Right Left Polyp(0,1,2,3) edema(0,1,2) Discharge(0,1,2)

For polyp,0-absence of polyp, 1-middle meatal polyp, 2-polyp beyond middle meatus, but not completely obstructing the nose, 3-polyps completely obstructing the nose

For edema, 0- absent, 1-mild, 2-severe

For discharge, 0-no discharge, 1-clear thin discharge, 2-thick purulent discharge

A score of 1 or above is considered abnormal

 CT scan Para nasal sinuses-coronal and axial cuts taken to

confirm the findings of diagnostic nasal endoscopy

 Basic investigation for assessment for surgery.(Hb%, TC,

DC, RBS, RFT, BT, CT, HIV, HbsAg etc were done

STUDY GROUP

Group 1-patients underwent endoscopic sinus surgery with partial middle turbinectomy

Group 2-patients underwent endoscopic sinus surgery without partial middle turbinectomy

The detail procedure was explained in the vernacular language and those patients willing to give written consent underwent the surgery. All cases were operated under local anaesthesia with prior prophylactic oral antibiotic medication

SURGICAL PROCEDURE

Under strict aseptic precautions all the cases were operated under local anaesthesia (2%lignocaine with adrenaline1:100,000). Patient in

Reverse Trendelenberg position,using 0 degree 4mm Hopkins rod endoscope routine endoscopic sinus surgery done. Partial middle turbinectomy done only for group 1 patients

Technique of partial middle turbinectomy

 Step 1- Middle turbinate is medially fractured to expose its vertical

attachment superiorly

 Step 2- Vertical attachment is incised with straight turbinate scissors at

its most anterior part

 Step 3- After this incision of the anterior superior attachment, the head

of the turbinate is grasped and dissected inferiorly and posteriorly

along the length of the turbinate back to the basal lamella

 Step 4- Incision of the posterior turbinate attachment completes the

partial resection followed which endoscopic surgery can proceed as

planned

Figure 4.1 Technique of partial middle turbinectomy

At the time of discharge from the hospital, the patients were given systemic antibiotics for 10 days and advised to do alkaline nasal douching for 1 month.

Regular follow up at 1week, 6 weeks and 3 months after surgery for subjective assessment regarding postoperative symptomatic relief ,and objective assessments like middle meatal patency and synechiae formation by check endoscopy and endoscopic cleaning

Post-operative follow up

 Regular follow up for atleast 3 months(1st week,6th week, 3rd month)

 Post-operative assessment by LUND AND MACKAY

ENDOSCOPIC SCORING SYSTEM at 1st week,6th week, 3rd

month

Table 4.2 The Lund Mackay endoscopic staging system for post

op assessment

The Lund Mackay staging system : endoscopic staging

GROUP 1 GROUP 2

Polyp (0/1/2/3)

Edema (0/1/2)

Discharge (0/1/2)

Crusting(0/1/2)

Scarring (0/1/2)

Total points

For polyp 0- absence of polyp, 1-middle meatal polyp, 2-polyps beyond middle meatus, but not completely obstructing the nose, 3 –polyps completely obstructing the nose

For edema, scarring crusting, synechiae 0- absent 1:mild 2:severe

For discharge: 0-no discharge 1:clear thin discharge 2:thick purulent discharge

A score of 1 or above is considered abnormal

DATA ANALYSIS:

Data collected were entered in Microsoft excel and analysed using

SPSS software. Association between endoscopic sinus surgery with and without partial middle turbinectomy analysed using Chi square test.

5.OBSERVATION AND RESULTS

5.1 Age distribution

A total of 50 patients with chronic rhino sinusitis were included in this study. The ages of the patient ranged from 22 to 49 years with mean age of 35.8 years. The minimum age in the study was 22 years and the maximum age was 49 years.72% of the patients were less than 40 years of age and 28% of the patients were more than 40 years of age. Their age distribution was as shown in the following table 5.1and figure 5.1

Age (in yrs)

N 50

Mean ± SD 35.8 ± 6.6

Minimum, Maximum 22, 49

Age Group N (%) (in yrs) <40 36 (72.0)

≥40 14 (28.0)

Total 50 (100.0)

Table 5.1

Figure 5.1

5.2 Gender distribution

The gender distribution in this study is as shown in the following table

5.2and figure 5.2. Of the 50 patients, 28 were males (56%) and 22 were females (44 %).

Gender N (%)

Male 28 (56.0)

Female 22 (44.0)

Total 50 (100.0) Table 5.2

Figure 5.2

5.3 Chief complaints

The most common presenting complaint was nasal discharge followed by unilateral or bilateral nasal obstruction, facial pain or headache and disturbance in smell. The frequency of presenting complaints were shown in following table 5.3 and figure 5.3

Group 1 Group 2 Presenting Complaints N (%) N (%)

Nasal Discharge 23 (92.0) 24 (96.0)

Nasal Obstruction 19 (76.0) 20 (80.0)

Facial Pain 14 (56.0) 14 (56.0)

Disturbance in smell 10 (40.0) 9 (36.0)

Table 5.3

Figure 5.3

5.4 Preoperative DNE scores

All patients in our study underwent diagnostic nasal endoscopic examination (DNE) and CT scans, both axial and coronal cuts before surgery. In group 1 and 2, no one had polyps on DNE assessment. In group

1 and 2, 28% had clear thin discharge and 72% had thick purulent discharge.

In group 1, 32% had mild edema and 68% had severe edema and in group 2,

20% had mild edema and 80% had severe edema.

Group 1 Group 2 Preop DNE Score N (%) N (%) Edema

Mild 8 (32.0) 5 (20.0)

Severe 17 (68.0) 20 (80.0)

Discharge

Clear Thin Discharge 7 (28.0) 7 (28.0)

Thick Purulent Discharge 18 (72.0) 18 (72.0)

Table 5.4

Figure 5.4.1

Figure 5.4.2

5.5 Comparison of DNE findings between two groups at postop assessment at first week

DNE SCORE SYMPTOMS GROUP N P value 0 1 Group 1 25 5 (20.0) 20 (80.0) OEDEMA 0.018 Group2 25 13 (52.0) 12 (48.0) Group 1 25 4 (16.0) 21 (84.0) DISCHARGE 0.059 Group 2 25 10 (40.0) 15 (60.0) Group 1 25 12 (48.0) 13 (52.0) SCARRING 0.152 Group 2 25 17 (68.0) 8 (32.0) Group 1 25 18 (72.0) 7 (28.0) SYNECHIAE 0.023 Group 2 25 10 (40.0) 15 (60.0) Group 1 25 14 (56.0) 11 (44.0) CRUSTING 0.396 Group 2 25 11 (44.0) 14 (56.0) Table 5.5

At the end of first week, there was stastistically significant p value of

0.018 for discharge and 0.023 for synechiae. The results are graphically represented in following graph

Figure 5.5

5.6 Comparison of DNE findings between two groups at post op

assessement at 6th week

DNE SCORE SYMPTOMS GROUP N 0 1 2 P value Group 1 25 20 (80.0) 5 (20.0) - OEDEMA 0.037 Group2 25 13 (52.0) 12 (48.0) - Group 1 25 21 (84.0) 4 (16.0) - DISCHARGE 0.016 Group 2 25 12 (48.0) 13 (52.0) - Group 1 25 15 (60.0) 10 (40.0) - SCARRING 0.123 Group 2 25 20 (80.0) 5 (20.0) - Group 1 25 20 (80.0) 5 (20.0) - SYNECHIAE 0.036 Group 2 25 12 (48.0) 10 (40.0) 3 (12.0) Group 1 25 19 (76.0) 6 (24.0) - CRUSTING 0.041 Group 2 25 12 (48.0) 13 (52.0) - Table 5.6

At the end of 6th week, there was significant p value of 0.016 for

discharge, 0.036 for synechiae, 0.037 for edema, 0.041 for crusting. The

results are graphically represented in the following graph.

Figure 5.6

5.7 Comparison of DNE findings between two groups at postop assessment at 3rd month

DNE SCORE SYMPTOMS GROUP N P value 0 1 Group 1 25 25 (100.0) - OEDEMA <0.001 Group2 25 14 (56.0) 11 (44.0) Group 1 25 24 (96.0) 1 (4.0) DISCHARGE 0.005 Group 2 25 15 (60.0) 10 (40.0) Group 1 25 20 (80.0) 5 (20.0) SCARRING 0.050 Group 2 25 25 (100.0) - Group 1 25 23 (92.0) 2 (8.0) SYNECHIAE 0.004 Group 2 25 13 (52.0) 12 (48.0) Group 1 25 23 (92.0) 2 (8.0) CRUSTING 0.008 Group 2 25 14 (56.0) 11 (44.0) Table 5.7

At the end of 3rd month, there was strongly significant p value of <0.001 for edema, 0.004 for synechiae, 0.005 for discharge, 0.008 for crusting. Not much significant p value for scarring(0.050). The results are graphically represented in following graph.

Figure 5.7

5.8 Comparison of postoperative symptom relief- Nasal discharge

Nasal Discharge Group N P value Absent Present

Postop Group 1 25 4 (16.0) 21 (84.0) st 0.114 1 Week Group 2 25 10 (40.0) 15 (60.0)

Postop Group 1 25 18 (72.0) 7 (28.0) th 0.083 6 Week Group 2 25 12 (48.0) 13 (52.0)

Postop Group 1 25 23 (92.0) 2 (8.0) rd 0.018 3 Month Group 2 25 15 (60.0) 10 (40.0) Table 5.8

Postoperatively, at first week follow up, 84% had nasal discharge in group 1(who underwent endoscopic sinus surgery with partial middle turbinectomy) when compared to 60% in group 2(who underwent endoscopic sinus surgery without partial middle turbinectomy). At 6th week of follow up, 28% in group 1 had nasal discharge compared to 52% in group

2. After 3 months follow up, 8% in group 1 had nasal discharge compared to 40% in group 2. There was significant p value of 0.018 for nasal discharge(symptom relief) at 3rd month follow up. The results are graphically represented in the following graph.

Figure 5.8

5.9 Comparison of postoperative symptom relief- Nasal Obstruction

Nasal Obstruction Group N P value Absent Present

Postop Group 1 25 18 (72.0) 7 (28.0) st 0.023 1 Week Group 2 25 10 (40.0) 15 (60.0)

Postop Group 1 25 20 (80.0) 5 (20.0) th 0.018 6 Week Group 2 25 12 (48.0) 13 (52.0)

Postop Group 1 25 24 (96.0) 1 (4.0) rd 0.001 3 Month Group 2 25 13 (52.0) 12 (48.0) Table 5.9

Postoperatively, at first week follow up, 28% had nasal obstruction in group 1(who underwent endoscopic sinus surgery with partial middle turbinectomy) when compared to 60% in group 2(who underwent endoscopic sinus surgery without partial middle turbinectomy). At 6th week of follow up, 20% in group 1 had nasal obstruction compared to 52% in group 2. After 3 months follow up, 4% in group 1 had nasal obstruction compared to 48% in group 2. There was significant p value of 0.001 for nasal obstruction(symptom relief) at 3rd month follow up. The results are graphically represented in the following graph.

Figure 5.9

No major surgical complications occurred in this study.

6. DISCUSSION

The invention and use of nasal endoscope revolutionized the treatment of chronic sinusitis. Now, endoscopic sinus surgery is used for the treatment of chronic rhino sinusitis not responding to medical management.

Functional endoscopic sinus surgery (FESS) is a minimally invasive procedure which aims to eradicate the diseased mucosa and improves the nasociliary clearance and improves the ventilation of paranasal sinuses.

When compared to other conventional surgeries, FESS has fewer complications and reduced rate of recurrence. But one disadvantage is the persistence of the disease after surgery and it is due to abnormal mucociliary clearance and persisting anatomical obstruction.

Various studies regarding failure of FESS showed stenosis of the natural ostium of the maxillary sinus and formation of synechiae to be the major contributing factors. Endoscopic sinus surgery with partial middle turbinectomy is a matter of debate for most of the surgeons. Those who oppose it suggest that middle turbinate is an important landmark for future surgery and should be preserved and those whose support suggests that the resection of middle turbinate can help in getting a better view of surgical field, and lower incidence of turbinate lateralization and better outcome.

This study was done to assess the role of partial middle turbinectomy with endoscopic sinus surgery in patients with chronic sinusitis.

In the present study involving 50 patients with chronic rhino sinusitis, preoperative symptoms and DNE scores are studied and post-operative results like DNE findings and symptom relief were compared between two groups (group 1- endoscopic sinus surgery with partial middle turbinectomy, group 2- endoscopic sinus surgery without partial middle turbinectomy). Out of the 50 subjects studied, socio-demographic variables such as age and sex were collected. In the study group, 56% were males and

44% were females. 72% were in the age group <40 years, 28% in >40years with a mean age group of 35.8 years. The most common presenting complaint was nasal discharge 92% in group 1 and 96% in group 2, followed by nasal obstruction 76% in group 1 and 80% in group 2 and facial pain or headache 56% in group 1 and 2 and disturbance in smell 40% in group 1 and 36% in group 2.

Preoperative diagnostic nasal endoscopic examination was done and score was given on the basis of Lund and Mackay endoscopic scoring system. On DNE examination preoperatively, 32% of the study subjects had mild edema and 68% of the study subjects had severe edema in group 1 and

20% of the study subjects had mild edema and 80% of the subjects had severe edema in group 2. 28% of the study subjects had clear thin discharge

80 and 72% had thick purulent discharge in group 1 and 28% had clear thin discharge and 72% had thick purulent discharge in group 2.

The postoperative outcome in the two groups were assessed both subjectively and also by endoscopy at fixed regular intervals.

This study shows that after 3 months follow-up, 92% had an improvement for nasal discharge postoperatively in patients who had undergone endoscopic sinus surgery with partial middle turbinectomy

(group 1) and 60% had an improvement for the same in patients who had undergone endoscopic sinus surgery without partial middle turbinectomy

(group2). The p value was 0.018 and showed that postoperative improvement for nasal discharge after partial middle turbinectomy is statistically significant. A study conducted by Santoshet al42. showed that after 6 months follow up 40% of the study subjects who underwent partial middle turbinectomy had improvement for nasal discharge postoperatively when compared to 20% of the study subjects who had undergone ESS without partial middle turbinectomy. Our study confirms to the findings of study conducted by Santosh et al.

This study also shows an improvement in nasal obstruction after partial middle turbinectomy. After 3 months follow up, 96% had improvement for nasal obstruction postoperatively in study subjects who

81 had undergone ESS with partial middle turbinectomy(group 1) and 52% had improvement for the same in study subjects who had undergone ESS without partial middle turbinectomy (group 2). The p value was0.001 and is strongly statistically significant

A study by Gulati et43alshowed that, 88% of study subjects who underwent

ESS with partial middle turbinectomy had improvement for nasal obstruction compared to 50% without partial middle turbinectomy. Our study confirms the findings of the study conducted by Gulati et al.

In our study, diagnostic nasal endoscopic examination after 3 month follow up shows strongly significant p value of <0.001,0.004,0.005,0.008 for edema, synechiae, discharge, crusting respectively. Not significant p value for scarring (p value 0.050).After 3 months follow up, 100% of the study subjects had improvement in group 1 patients and 56% of the study subjects had improvement in group 2 patients for edema. 96% of the study subjects had improvement in group 1 and 60% of the study subjects had improvement in group 2 for nasal discharge. 92% had improvement for synechiae in group 1 and 52% had improvement for synechiae in group 2.

92% had improvement for crusting in group 1 and 56% had improvement for crusting in group 2.

A study conducted by Santoshet al42 showed strongly significant p value of 0.000, 0.002, 0.000 for edema, discharge and synechiae respectively and moderately significant p value of 0.047 for crusts.

A study conducted by Gopiet al44 showed that 83.3% had patent antrostomy and osteomeatal complex who underwent partial middle turbinectomy but only 70% had patent antrostomy and osteomeatal complex who had middle turbinate preservation. A study by Lamearet al45reported that partial middle turbinectomy were safe and antrostomy and osteomeatal complex patency rates 30% higher than middle turbinate preservation technique.

Above studies show an increase in middle meatal patency rates in postoperative periods of study subjects who underwent partial middle turbinectomy. And our study confirms to the findings of above studies.

A study conducted by Gopi et al44 showed that 3.3% had synechiae who underwent partial middle turbinectomy but 26.7% had synechiae who had middle turbinate preservation. A study conducted by Santoshet al42 showed that only 5% had synechiae who underwent partial middle turbinectomy but

25% had synechiae who had middle turbinate preservation

Above studies shows reduction in synechiae formation in postoperative periods of study subjects who underwent partial middle turbinectomy.

In our study, patients who underwent partial middle turbinectomy shows better postoperative symptomatic relief and good improvement in diagnostic nasal endoscopy compared to the patients with middle turbinate preservation.

7. CONCLUSION

This study was conducted to compare the outcome of endoscopic sinus surgery with partial middle turbinectomy and endoscopic sinus surgery without partial middle turbinectomy in patients with chronic rhinosinusitis. And the study shows statistically significant p values in postoperative Diagnostic nasal endoscopic scores in terms of edema, discharge, synechiae and crusting and statistically significant postoperative symptomatic relief in nasal discharge and nasal obstruction in study subjects who underwent partial middle turbinectomy when compared to the study subjects who had middle turbinate preservation.

As per the study, partial middle turbinectomy is reasonable as it probably prevents adhesions between the remaining middle turbinate and the freshly incised lateral nasal wall and also it improves the patency of the middle meatus. It also increases the access for future endoscopic cleaning and examination of maxillary sinus, frontal recess and ethmoid infundibulum.

By preserving the posterosuperior part of middle turbinate we had preserved important landmarks for future surgery and disruption of nasal physiology and atrophic rhinitis was avoided. This study concludes that partial middle turbinectomy is a positive variable and an adjuvant technique in patients with chronic rhino sinusitis in terms of the improvement of maintenance of ventilation of osteomeatal complex and symptomatic relief.

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355

ANNEXURE

INFORMED CONSENT FORM

1. I confirm that I have read and understood the information letter for the

above study and have had the opportunity to clear doubts.

2. I understand that my participation in the study is voluntary and that I’m

free to withdraw at any time, without giving any reason, without my

medical care or legal rights being affected.

3. I understand that the ethics committee and the regulatory authorities will

not need my permission to look at my health records both in respect of

the current study and any further research that may be conducted in

relation to it even if I withdraw from the trial. I agree to this access.

However I understand that my identity will not be revealed in any

information released to third parties or published.

4. I agree not to restrict the use of any data or results that arise from this

study provided such a use is only for scientific purposes.

5. I agree to take part in the above study.

Signature of the subject: Signatory’s name:

Signature of the investigator: Study investigator’s name:

Signature of impartial witness: Name of impartial witness:

PROFORMA

NAME : SERIAL NO. : AGE : HOSPITAL NO : SEX : DATE : ADDRESS : CONTACT NO :

CHIEF COMPLAINTS:

PRESENT HISTORY

SYMPTOMS NO (0) YES (1) REMARKS

Nasal Discharge

Nasal

Obstruction

Facial pain

Post nasal drip

Sneezing

Loss of smell

Epistaxis

Asthma

Dust allergy

Others

History of past illness:

THYROID SURGERY IRRADIATION TB(1) HTN(2) DM(3) BA(4) CAD(5) DISEASES (7) (8) (6)

Similar Complaints In History of any surgery in Drug Allergy (9) Past (10) past (11)

Personal history

Diet Vegetarian(0) Mixed(1)

Sleep Normal(0) Reduced(1) Increased(2)

Appetite Normal(0) Reduced(1) Increased(2)

Bowel and Normal(0) Abnormal(1) Bbladder habits

No Yes Smoking (0) (1)

Pan / Tobacco No Yes

chewing (0) (1) Addictions No Yes Alcoholism (0) (1)

No Yes Snuffing (0) (1)

Family History:

H/o malignant disease similar Tuberculosis(2) others(4) (1) complaints(3)

ENT EXAMINATION

Examination of NOSE

Normal(0) Abnormal(1) Remarks

Face

External nose

Cold spatula test columella vestibule

ANTERIOR RHINOSCOPYRIGHT LEFT Remarks

Normal Abnorm Normal Abnorm

(0) al (1) (0) al (1)

Mucosa

Turbinates –Inferior Middle

Superior

Meati–Inferior Middle

Superior septum Normal Abnormal

POST NASAL LEFT Remarks EXAMINATIONRIGHT

Choanae

Post. end of septum

Post. end of turbinates

Eustachiantube opening

Examination of Right Left Remarks Paranasal Sinus

Frontal

Ethmoid

Maxillary

Examination of ORAL CAVITY & THROAT

Normal (0) Abnormal (1)

Examination OF EAR

Normal (0) Abnormal (1) Remarks

RIGHT

LEFT

DIAGNOSIS PREOPERATIVE EVALUATION

1. DIAGNOSTIC NASAL ENDOSCOPY:

The Lund Mackay staging system : endoscopic staging

Right Left Polyp(0,1,2,3) edema(0,1,2) Discharge(0,1,2)

For polyp, 0-absence of polyp, 1-middle meatal polyp, 2-polyp beyond middle meatus, but not completely obstructing the nose, 3-polyps completely obstructing the nose

For edema, 0- absent, 1-mild, 2-severe

For discharge, 0-no discharge, 1-clear thin discharge, 2-thick purulent discharge

A score of 1 or above is considered abnormal

2. Basic investigation for assessment for surgery.(Hb%, TC, DC, RBS,

RFT, BT, CT, HIV, HbsAg etc were done

3.CT scan Paranasal sinuses-coronal and axial cuts taken to confirm the findings of diagnostic nasal endoscopy

DIAGNOSIS :

TREATMENT :

Group 1: study subjects underwent endoscopic sinus surgery with partial middle turbinectomy

Group 2: study subjects underwent endoscopic sinus surgery with middle turbinate preservation

100

POSTOPERATIVE ASSESSMENT

1. Diagnostic nasal endoscopic examination done based on Lund

Mackay endoscopic staging system at 1st , 6thweek and 3rd month

The Lund Mackay staging system : endoscopic staging

GROUP 1 GROUP 2

Polyp (0/1/2/3)

Edema (0/1/2)

Discharge (0/1/2)

Crusting(0/1/2)

Scarring (0/1/2)

Total points

For polyp 0- absence of polyp, 1-middle meatal polyp, 2-polyps beyond middle meatus, but not completely obstructing the nose, 3 –polyps completely obstructing the nose

For edema, scarring, crusting, synechiae 0- absent 1:mild 2:severe

For discharge: 0-no discharge 1:clear thin discharge 2:thick purulent discharge

A score of 1 or above is considered abnormal

2.Subjective assessment of postoperative symptomatic relief

101

KEY TO MASTER CHART Group 1 : Study subjects who underwent endoscopic sinus surgery with partial middle turbinectomy

Group 2 : Study subjects who underwent endoscopic sinus surgery with middle turbinate preservation

ND : Nasal discharge

NO : Nasal obstruction

FP : Facial pain

DS : Disturbance in smell

ED : Edema

D : Discharge

Crus : Crusting

Scar : Scarring

Syne : Synechiae

DNE : Diagnostic Nasal Endoscopic examination

PARAMETERS ASSESSED

 PREOP: Polyp, edema, discharge

 POSTOP: Polyp, edema, scarring, crusting, discharge, synechiae

102

SCORES

 Polyp 0: absence of polyp

 Discharge: 0=no discharge,1:clear thin discharge, 2:thick purulent

discharge

 For oedema, scarring, crusting, synechiae

0:absent, 1:mild,2:severe

103

MASTER CHART

104

Preop DNE post op- postop DNE scores- post op- post op DNE scores- post op- 3 post op DNE scores-3 group 1 Presenting symptoms scores 1st week 1st week 6th week 6th week months months

Sl.no Age Sex ND NO FP DS Polyp ED D ND NO ED D Crus Scar syne ND NO ED D Crus Scar Syne ND NO ED D Crus Scar Syne 1 30 M P P A A 0 2 2 P A 1 1 1 1 1 A A 1 1 1 1 0 A A 0 0 0 0 0 2 35 M P P P A 0 1 1 P P 1 1 1 0 0 A A 0 0 0 0 0 A A 0 0 0 0 0 3 28 M P P P A 0 2 2 P A 1 1 1 1 1 P A 1 0 0 1 1 A A 0 0 0 0 0 4 25 F P P P P 0 1 2 P A 1 1 1 1 1 A A 1 1 0 1 0 A A 0 0 0 0 0 5 40 F P P P P 0 2 2 P A 0 1 0 0 0 A A 0 0 0 0 0 A A 0 0 0 0 0 6 45 M P P A A 0 2 2 P P 1 0 0 1 1 A A 0 0 0 0 1 A A 0 0 0 0 0 7 29 F P P A A 0 2 2 P A 1 1 1 0 0 P A 0 0 0 0 0 A A 0 0 0 0 0 8 34 M P P P P 0 1 1 A P 0 0 0 1 1 A A 0 0 0 0 1 A A 0 0 0 0 0 9 36 M A P A A 0 1 2 P A 1 1 0 0 0 P A 0 0 0 0 0 A A 0 0 0 0 0 10 39 F P A P A 0 2 1 P A 1 1 1 0 0 P P 0 0 0 1 0 A A 0 0 0 0 0 11 42 M P P A P 0 2 2 P P 1 1 1 0 0 A A 0 0 0 0 0 A A 0 0 0 0 0 12 35 F P A P A 0 2 1 P A 1 1 0 0 0 P P 0 0 0 1 0 A A 0 0 0 0 0 13 46 M P P P A 0 2 2 P A 1 1 1 0 0 A A 0 0 1 1 0 A A 0 0 0 0 0 14 27 M P A A P 0 1 2 P A 1 1 1 0 0 P A 0 0 0 0 0 P A 0 1 1 1 1 15 25 F P A P A 0 1 1 P A 1 1 1 0 0 A A 0 0 0 0 0 A P 0 0 1 1 1 16 49 M P P A A 0 2 2 A P 1 0 0 1 1 A A 0 0 0 0 0 A A 0 0 0 0 0 17 35 M P P P P 0 1 2 P A 1 1 1 1 1 A A 0 1 1 1 1 A A 0 0 0 1 0 18 36 M P P P A 0 2 1 P A 1 1 0 1 0 A P 1 0 1 1 1 A A 0 0 0 1 0 19 44 F P A A A 0 2 2 A A 0 1 0 0 0 P A 0 0 0 0 0 P A 0 0 0 1 0 20 22 F A P A P 0 2 2 P P 1 1 0 0 0 A A 0 0 0 0 0 A A 0 0 0 0 0 21 31 M P P P P 0 2 2 P A 1 1 0 1 0 A P 0 0 0 0 0 A A 0 0 0 0 0 22 37 F P P P A 0 2 2 A A 0 0 0 1 0 A A 0 0 0 0 0 A A 0 0 0 0 0 23 39 M P P A P 0 1 1 P A 0 1 0 1 0 A A 0 1 1 1 0 A A 0 0 0 0 0 24 40 F P A P A 0 2 2 P P 1 1 0 1 0 A P 0 0 0 0 0 A A 0 0 0 0 0 25 37 F P P A P 0 2 2 P A 1 1 0 1 0 A A 1 0 1 1 0 A A 0 0 0 0 0

105 group 2 Preop DNE post op- postop DNE scores- post op- post op DNE scores- post op- 3 post op DNE scores-3 Presenting symptoms scores 1st week 1st week 6th week 6th week months months

Sl.no Age Sex ND NO FP DS Polyp ED D ND NO ED D Crus Scar syne ND NO ED D Crus Scar Syne ND NO ED D Crus Scar Syne 1 35 M P P A A 0 2 2 P P 0 1 0 0 1 P P 1 1 1 0 1 P P 0 0 0 0 0 2 36 M P P A A 0 2 1 P P 1 0 0 1 1 A A 0 0 0 0 1 A P 0 0 0 0 1 3 27 F P P A A 0 1 2 A A 1 0 1 0 1 A A 0 0 0 0 1 A A 0 0 0 0 1 4 42 F P P P A 0 2 1 P P 0 0 0 0 1 A A 0 0 0 0 1 A A 0 0 0 0 0 5 25 F P P P A 0 2 2 P P 1 1 1 1 0 P P 1 1 1 0 0 P P 1 1 0 0 0 6 41 M P P A P 0 2 1 A A 1 1 1 1 0 P P 1 1 1 0 0 P P 1 1 1 0 0 7 37 M P A A P 0 2 2 P P 0 0 0 0 0 A A 0 0 0 0 0 A A 0 0 0 0 0 8 34 F A P P A 0 1 2 A A 0 0 0 0 0 A A 0 0 0 0 0 A A 0 0 0 0 0 9 39 M P P P P 0 2 2 P P 1 0 1 1 0 A A 1 1 1 0 0 A P 0 0 1 0 0 10 29 M P P A P 0 1 1 P A 1 1 1 1 1 P P 1 1 1 0 2 A P 1 1 1 0 1 11 43 F P P P A 0 2 1 P P 0 0 0 0 0 P P 0 0 0 0 0 A A 0 0 0 0 0 12 45 F P A A A 0 2 2 A A 1 1 1 1 1 P P 1 1 1 1 2 P A 1 1 1 0 1 13 39 M P P P A 0 2 2 P P 1 1 1 1 1 P P 1 1 1 0 2 P P 1 1 1 0 1 14 47 M P P P A 0 2 2 A A 0 0 0 0 0 A A 0 0 0 0 0 A A 0 0 0 0 0 15 27 M P A A A 0 2 2 P P 0 1 1 1 1 P P 0 1 1 0 1 P A 1 1 1 0 1 16 32 F P P A A 0 2 2 A A 1 0 1 0 1 A A 0 0 0 0 1 A A 1 0 1 0 1 17 37 F P P P P 0 2 1 P P 0 0 0 0 0 A A 1 1 1 0 0 A A 0 0 0 0 0 18 35 M P P P P 0 2 2 A P 0 1 0 0 0 P P 0 0 0 0 0 P A 0 0 0 0 0 19 39 F P P P P 0 2 2 A A 1 1 1 0 1 P P 1 1 1 1 0 A A 1 1 1 0 1 20 29 M P A A P 0 2 2 P P 1 1 1 0 1 A A 1 0 0 0 1 P P 1 1 1 0 1 21 49 F P P P P 0 2 2 A A 0 1 1 0 1 P P 0 0 0 0 1 A P 1 1 1 0 1 22 40 M P P P A 0 1 2 P P 0 1 1 0 1 P P 1 1 1 1 1 P A 0 0 0 0 1 23 36 M P P P A 0 2 2 A A 1 1 1 0 1 P P 1 1 1 1 1 A P 1 1 1 0 1 24 37 M P A A A 0 1 1 P P 0 1 0 0 0 A A 0 1 1 1 0 A P 0 0 0 0 0 25 28 F P P P A 0 2 2 P P 0 1 0 0 1 A A 0 0 0 0 0 P P 0 0 0 0 0 Preop DNE post op- postop DNE scores- post op- post op DNE scores- post op- 3 post op DNE scores-3 group 1 Presenting symptoms scores 1st week 1st week 6th week 6th week months months

group 2 Preop DNE post op- postop DNE scores- post op- post op DNE scores- post op- 3 post op DNE scores-3 Presenting symptoms scores 1st week 1st week 6th week 6th week months months

106

107