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

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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 1 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. 2 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. 3 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 4 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 6 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 7 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 8 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 9 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. 11 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. 12 2. AIM OF THE STUDY 1) To compare and study the outcome of endoscopic sinus surgery with and without partial middle turbinate resection.
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