Comparison of Outcome of Endoscopic Septoplasty versus Endoscopic Septoplasty with Inferior Turbinoplasty Using Microdebrider

Thrupthi S^*, Rajasekar MK and Jayapreetha

^*Correspondence: Thrupthi S, Department of ENT, Sree Balaji Medical College and Hospital, Chrompet, Chennai, Tamil Nadu, India, Email:

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Introduction

Breathing is an individual's most basic need for survival. It has an impact not only on an individual's survival but also on his or her productivity. Breathing difficulties can be caused by abnormalities ranging from the tip of the nose to the terminal bronchioles.

Nasal obstruction is one of the common symptoms that patients present with to the ENT surgeon. The development of new diagnostic and therapeutic materials has helped to a variable extent to understand the various anatomical abnormalities or any pathology. Symptoms maybe disproportionate to the actual findings. I will be discussing the management of nasal obstruction in my study.

The most common causes of nasal obstruction are deviated nasal septum and inferior turbinate hypertrophy. Many patients complain of persisting nasal obstruction after undergoing septoplasty as a treatment for deviated nasal septum. It is usually due to the presence of a hypertrophied inferior turbinate. Diagnostic nasal endoscopy is done preoperatively to show the difficulty in the first pass which maybe caused due to the deviated nasal septum as well as inferior turbinate hypertrophy. Temporary management of turbinate reduction can be done using modern pharmacological agents. It is temporary as the nasal obstruction is bound to occur after the stoppage of medical treatment. Alternatively patient can undergo turbinate reduction procedures as a treatment option for inferior turbinate hypertrophy [1]. The chances of crusting, atrophic rhinitis is high with total turbinectomy but nevertheless it relieves nasal obstruction immediately. The other procedures which can be done for turbinate reduction are:

These are the resection procedures

1. Partial inferior turbinectomy

2. Subtotal inferior turbinectomy

3. Turbinate submucous resection

4. Inferior turbinoplasty with power

Non-resection procedures include

1. Turbinate out fractioning

2. Chemical turbinate cauterization

3. Cryotherapy

4. Surface and submucosal electrocautery

5. Radiofrequency ablation

6. Coblation assisted turbinoplasty

7. LASER assisted turbinoplasty

My study is about the added benefits of microdebrider assisted turbinoplasty when it is done alongwith septal correction procedures [2].

The study's goals and objectives

The purpose of this study was to compare the outcomes of endoscopic septoplasty and endoscopic septoplasty combined with microdebrider assisted inferior turbinoplasty by

• Comparing symptomatic improvement in the various groups.

• Comparing the postoperative complication rates in the control and test groups.

Materials and Methods

Aim: To compare the outcomes of endoscopic septoplasty and endoscopic septoplasty combined with inferior turbinoplasty assisted by a microdebrider.

December 2017 to November 2019 Study Period.

Criteria for inclusion

• Age 20 to 45 years old, both sexes.

• Patients with a deviated nasal septum, inferior turbinate hypertrophy, and nasal obstruction symptoms.

• The patient gives his or her consent to participate in the study.

• The patient is willing to undergo surgery [3].

Exclusion criteria

• Patients over the age of 45 and those under the age of 20 are excluded.

• Patients who have a history of allergic reactions or other symptomatology.

• Patients who are unable to undergo surgery.

Investigations

A complete history with systemic examination and complete examination of ear, nose and throat including anterior and posterior rhinoscopy [4].

• Diagnostic nasal endoscopy.

• CT paranasal sinuses.

• Preop and post op questionnaire.

• Routine pre-operative investigations (complete blood counts, renal function tests, etc.)

Case presentation

The prospective study was conducted at Sree Balaji Medical College and Hospital, Chennai. The patients who came to the ENT op with symptoms of deviated nasal septum and inferior turbinate hypertrophy both clinically and radiologically were studied after taking the inclusion criteria into careful consideration (Figure 1).

Figure 1: CT PNS.

It was essentially a double-blind prospective randomised control study in which all patients in the even number were assigned to septoplasty plus inferior turbinoplasty and all patients in the odd number were assigned to septoplasty alone [5].

General anaesthesia was preferred to do the procedure. Approximately 3-4 ml was injected into the sub-mucosa of both the inferior turbinates and the submucoperichondrial layer of the nasal septum. For surface decongestion of the nasal mucosa along with topical decongestion, cotton patties which was soaked in 4% lignocaine with adrenaline was used. For general anaesthesia, a 1:20000 concentration adrenaline is used for surface anaesthesia and a 1:200000 adrenaline solution as injection is used to prevent excess intraoperative bleeding. Septoplasty is performed with a zero degree Hopkins endoscope following infiltration and a Freer's incision on the nasal septum on the side of caudal displacement of the nasal septum, (Figure 2).

Figure 2: Mucoperichondrial and mucoperiosteal flaps.

This is followed by raising the mucoperichondrial and mucoperiosteal flaps on the same side of the incision. Then incision is made at the bony cartilaginous junction of the nasal septum and the opposite side of the mucoperiosteum is elevated (Figure 3).

Figure 3: Septal spur.

Septal spur with the deviated septum is removed using a Ballenger swivel knife. Mucoperichondrial and mucoperiosteal flaps are repositioned and sutured [6]. A vertical incision is made in the anterior aspect of the inferior turbinate after infiltrating it using a zero degree Hopkins rigid endoscope.

Figure 4: Turbinoplasty blade size 2.9 mm.

Then a microdebrider with a straight blade is inserted into the incision and along the medial aspect of the inferior turbinate the submucosal soft tissue is debrided out. A submucosal tunnel is created along the medial aspect of the inferior turbinate [7].

Hemostasis is achieved by placing cotton patties. Once hemostasis is achieved, nasal packing is done with gauze soaked in 1:20000 adrenalines. Nasal packs are removed after 24 hours (Figure 5).

Figure 5: Microdebrider assisted turbinoplasty.

Preoperatively and 3 months postoperatively the patients were given a questionnaire and asked to score the symptoms and improvement in lifestyle. SNOT-20 (sinonasal outcome test-20) original research, which was published in the journal of otorhinolaryngology, head and neck surgery (2007).

Modifications were done in the original SNOT-20 scoring system to satisfy the needs of our study. Five parameters were used for the analysis of nasal symptoms like irritability, nose block, facial pain, reduced concentration and difficulty in falling asleep (Figure 6).

Figure 6: Post op DNE left side with adequate first pass.

If the first pass is inadequate it means that either the scope cannot be passed to visualize the choana or the scope will be passed with great difficulty whereas adequate first pass indicates that the scope can be passed easily to visualize the choana [8].

Results and Discussion

A sample size of 100 patients were considered for the study out of which 50 patients underwent septoplasty alone and considered as the control group and the rest underwent septoplasty with inferior turbinoplasty using a microdebrider as considered to be the test group.

Out of the 50 patients who were taken as the test group, 23 patients underwent bilateral turbinoplasty, 18 had left turbinoplasty and 9 of them underwent right turbinoplasty along with septoplasty. The groups were randomized into test and control groups [9]. The improvement in symptoms and post objective diagnostic nasal endoscopy were considered at the end of 3 months which is better in the test group as compared to the control group to consider this study a success (Table 1).

Table 1: Total symptom score.