Middle turbinate medialization for improved …

1 ORIGINAL ARTICLEM iddle turbinate medialization for improved access during endoscopicsinus surgeryMichael R. Lee, MD, Bradley F. Marple, MDIntroduction:Proper management of the Middle turbinatein endoscopic sinus surgery is o en a topic of debate. Mostauthors, however, agree in the need to prevent lateraliza-tion. We describe our preferred technique and stress thetiming of the medialization :The Middle turbinates are sutured to the nasalseptum at the beginning of the operation. This allows opti-mal access to the nasal cavity and paranasal sinuses duringthe entirety of the :Multiple techniques have been described toprevent lateralization of the Middle turbinate .

2 It is our opin-ion that implementing the proposed technique at the startof the surgery allows for optimal exposure during the 2011 ARS-AAOA, Words:endoscopic sinus surgery; Middle turbinate ; middleturbinate medialization ; lateralization; surgical expo-sure; nasal septum; conchopexy; synechiae; ostiomeatalcomplexHow to Cite this Article:Lee MR, Marple BF. Middle turbinate medialization for im-proved access during endoscopic sinus ForumAllergy Rhinol,2011; 1:187 190 The role of the Middle turbinate as a vital landmarkduring endoscopic sinus surgery has been well estab-lished.

3 Proper management of this important structure,however, remains somewhat ,2 Some au-thors have suggested either partial or complete resectionboth to accommodate postoperative care and more im-portantly to prevent scar formation and lateralization ofthe turbinate to the lateral nasal wall. Lateralization ofthe Middle turbinate is a concern, considering the poten-tial for obstruction of the ostiomeatal ,4In orderto preserve the Middle turbinate and prevent lateralization,several techniques have been previously 6 Wediscuss Middle turbinate medialization , with emphasis ontiming of this technique at the initiation of surgery to allowoptimal access to the uncinate process, infundibulum, andother important structures during endoscopic sinus methodFollowing administration of general anesthesia, the pa-tient s nose is decongested with oxymetazoline-treatedpledgets.

4 Local anesthetic is then introduced into the nasalSouthwestern Medical Center, University of Texas, Dallas, TXCorrespondence to: Michael Lee, MD, 212 Landry Court, Irving, TX 75063;e-mail: conflict of interest: None : 6 June 2010; Revised: 31 July 2010; Accepted: 14 September 2010 DOI: this article online at of the septum, Middle turbinate , and uncinate pro-cess. The pterygopalatine fossa is also injected. The nasalpledgets are now reintroduced and the patient is preppedand draped. Endoscopic septoplasty is performed when nec-essary. At this time the pledgets are removed and with theassistance of the 0-degree endoscope we perform middleturbinate medialization .

5 A 4-0 vicryl suture on a P3 needleis obtained and the needle is partially straightened (Fig. 1).The needle retains some curvature but the slight straighten-ing allows easy passage through the tissue. The needle is ini-tially passed lateral to medial through the Middle turbinateand then through the nasal septum (Fig. 2). The trajec-tory carries the needle through the contralateral middleturbinate. On occasion, the endoscope is used to secure themiddle turbinate while the needle is being passed needle is now retrieved and passed back throughthe septum anterior to the head of the Middle turbinate (Figs.)

6 3 and 4). Once the needle passes through the septumto the initial side the suture is tied with the use of a bayonetneedle driver (Figs. 5 and 6). An assistant holds the endo-scope so that the knot is tied under direct visualization. Thesuture is left in place throughout the operation and at theconclusion to prevent lateralization of the turbinate andadhesion of the Middle turbinate is a common causeof recalcitrant ,3 Thorton4discussed his experi-ence in 31 patients undergoing endoscopic sinus Forum of Allergy & Rhinology, Vol. 1, No. 3, May/June 2011 Lee and MarpleFIGURE P3 needle is slightly straightened with the use of a hemostatto facilitate passage through Middle turbinate and all patients a turbinate transseptal suture was appliedto medialize the Middle turbinate .

7 He reported a patentmiddle meatus in all but 1 patient in which the suturehad parted. Thorton4concluded that by applying the su-ture stabilization of the Middle turbinate one could pre-vent scarring and obstruction of the Middle meatus. Severalother surgeons have reported using the suture stabilizationor conchopexy 7We suggest performing themedialization technique at the beginning of the operationto allow greater access to the nose and paranasal sinusesduring a retrospective review of suture medialization , He-witt and Orlandi6reported the results regarding 85 pa-tients treated with endoscopic sinus surgery.

8 They soughtto ascertain the incidence of postoperative Middle turbinateadhesion to the lateral nasal wall. They found adhesionsoccurring in only 10% of patients and that only 4 ofFIGURE suture is initially passed in a lateral to medial directionthrough the Middle needle is received after penetrating the septum and con-tralateral Middle 157 Middle turbinates developed synechiae substan-tial enough to become clinically significant. They con-cluded that the development of clinically significant ad-hesions following medialization of the Middle turbinateis uncommon and the technique should be considered asan alternative to packing or stenting of the nasal and Hicks8described a technique in which themiddle turbinate was medialized with a Cottle elevatorwhile a 1-cm 1-cm Merocel sponge was placed intothe Middle meatus between the ethmoid bulla and themiddle turbinate .

9 Normal saline was then applied to thesponge, which when expanded allowed better visualiza-tion of the area. At the conclusion of the operation theyremoved the smaller packing and placed a much larger Me-rocel sponge to maintain a medialized Middle have suggested the idea of controlled therapeu-tic synechiae. Bolger et their experienceFIGURE retrieval of the needle in the contralateral nasal cavity,the suture is brought anterior to the Middle turbinate and passed backthrough the Forum of Allergy & Rhinology, Vol. 1, No. 3, May/June 2011188 Middle turbinate medializationFIGURE needle is now identified in the initial nasal cavity and tiedsecurely.

10 With the Middle turbinate medialized, the uncinate process is iden-tifiable and more easily accessible during the patients following ethmoidectomy in which the mid-dle turbinate lacked structural fortitude. In these patients,4 shallow mucosal incisions were made on the medial aspectof the Middle turbinate using a sickle knife. On the nasalseptum, just opposite of the turbinate , additional incisionswere made to violate the mucosa. Packing was then placedin the Middle meatus, forcing the Middle turbinate to abutthe nasal packs were removed 24-48 hourslater. The authors admit to variation in postoperative careand that occasionally Gelfilm would be placed after pack-ing removal to further prevent scarring9; they cited tech-nical difficulty and invariable results related to concernswith suture stabilization.