Peri-operative measures to prevent middle turbinate lateralisation and adhesion formation in endoscopic sinus surgery: a systematic review of the literature

Background: Chronic rhinosinusitis (CRS) is a common sinonasal condition carrying a significant disease burden, frequently requiring specialist otolaryngologist referral. Endoscopic sinus surgery (ESS) is often indicated where medical management fails. Occasionally, ESS may fail and revision surgery may be required. Middle turbinate lateralisation and adhesion formation (MiTLAF) is a common cause of failed ESS. Various MiTLAF prevention techniques have been described, including Bolgerisation, middle turbinate conchopexy, silastic splint placement, middle meatal spacers, hyaluronic-acid based packing, and middle turbinate resection. However, there is limited evidence in the literature comparing techniques. The aim of this study was to systematically review the literature regarding MiTLAF prevention techniques in ESS. Methods: A systematic review of the literature was performed following the PRISMA guidelines. Embase, Ovid-Medline, and Ovid-PubMed databases were searched for eligible studies pertaining to synechiae development post-ESS. Articles that due to the following reasons: insufficient data published, patients undergoing procedures other than ESS, and review articles, were excluded. The QUADAS-2 model was used for risk of bias analysis. The primary outcome of the study was the efficacy of each technique in synechiae prevention. Secondary outcomes included complication rates and CRS outcome-measures. Results: Four hundred and twelve studies met the search criteria, of which 30 studies were eligible for inclusion (Bolgerisation: 2, middle turbinate conchopexy: 5, silastic splint placement: 5, middle meatal spacers: 9, hyaluronic acid spacers: 5 and middle turbinate resection: 7). Based on the literature reviewed, the most effective techniques in preventing MiTLAF were silastic splints (MiTLAF rate range 0–8%) and conchopexy (0–10.8%). Although effective, higher MiTLAF rates were seen with Bolgerisation (10–15%), steroid-eluting absorbable spacers (4.8–5.3%) and middle turbinate resection (0–16.1%). The least effective techniques evaluated were nonabsorbable spacers (8.1% to 35.7%) and other absorbable spacers, including hyaluronic acid (3.8–20.3%). Meta-analysis was not possible due to significant heterogeneity in study design. This review was also limited by the lack of high-quality studies available. Conclusions: The reviewed literature suggests that silastic splints and conchopexy are most effective in MiTLAF prevention, with the lowest complication rates. The results of further randomised controlled studies are required to support these conclusions. In particular, the use of absorbable spacers and middle turbinate resection both require further investigation to substantiate their purported efficacy and long-term safety.