2016 Section 5 Green Book

TABLE II. Summary of Evaluated Studies Included in This Review in Chronological Order.

First Author (year of publication)

Number of Patients

Age (years)

Gender Distribution (male:female)

Implant Material

Surgical Approach

Outcome Measures

Follow-up (months)

Jiang (2014)

24

18–64

18:6

Medpor

Transnasal SNOT-25

3,6,12

Tam (2014)

16

31–68

10:6 22:9

Medpor

Transnasal SNOT-22 Transnasal SNOT-25

12

Jung (2013)

31 Mean 43.5

Conchal, costal cartilage

6

Bastier (2013)

5 49.2–54.7

3:2

Nonporous

Transoral

NOSE,

Mean 13.5, Range 8.2–21

b -tricalcium phosphate

RhinolQoL

12 3 AlloDerm, 12 3 Silastic

Saafan (2013)

24 Mean 27

11:13

Transnasal SNOT-25

Mean 18, Range 9–24

Modrzynski (2011)

3

48–64

2:1

Hyaluronic acid gel

Transnasal Subjective, acoustic rhinometry Transnasal 10-point visual analogue scale

12

Jang (2011)

17

20–66

11:6

Cartilage

Mean 11.8, Range 6 - 27

(autologous, homologous)

Houser (2007)

8

18–45

7:1

AlloDerm

Transnasal SNOT-20

Range 6–48

NOSE 5 Nasal Obstruction Symptom Evaluation; RhinolQOL 5 Rhinosinusitis Quality of Life; SNOT 5 Sino-Nasal Outcome Test.

candidates was undertaken in three studies. 18,21,23 Most patients had been suffering with ENS for many years (up to 29.7 years 12 ), and there was general consensus that ENS surgery was deferred for at least 1 year after turbinectomy. Although all studies reported on patients who had inferior turbinectomy, the degree of turbinate resection (partial, total) was not consistently reported. Surgical Technique The most common surgical technique involved a transnasal approach, with implant material secured within a submucosal pocket. The amount and thickness of implant material was arbitrarily decided based on how much inferior turbinate reconstruction was necessary at the time of the operation. Multiple implant sites in the lateral nasal wall, remnant of the inferior turbinate or septal area adjacent to the resected turbinate, were nor- mally performed to narrow the nasal valve region. Com- mon implant material used in the studies included noncellular dermis (AlloDerm) and porous high-density polyethylene (Medpor, Porex Surgical, Inc., GA). These materials were used in 47% of cases, whereas autologous (septal, conchal) and homologous (Tutoplast-processed cos- tal cartilage; Tutogen Medical GmbH, Neunkirchen am Brand, Germany) cartilage was utilized in 38% of cases. In three cases, small aliquots (0.3–0.4 mL) of hyaluronic acid gel (Juvederm; Allergan, Inc., CA) was injected into the remnant of the head of inferior turbinate, and adja- cent septum after the nasal mucosa was perforated with a CO2 laser. 25 One study involving five patients embedded nonporous b -tricalcium phosphate (SINUS UP; Kasios, Launaguet, France) via a gingival incision within a sub- mucoperiosteal pocket in the lateral nasal wall. 12

on an aggregated follow-up period, although two presented results at 3-, 6-, and 12-month follow-up. 12,18 Of the eight studies, seven assessed clinical efficacy with a patient- reported outcome tool (Table II). Five studies utilized the SNOT, totaling 103 patients. The weighted mean preopera- tive SNOT-20 and SNOT-25 scores were 48.3 and 65.9 respectively. At the latest follow-up, these scores improved significantly ( P < 0.05) to 24.4 and 33.3, respectively. Averaged scores of individual SNOT questions were available from 64 patients, which enabled the analysis of SNOT subdomains. 12,18,22 High SNOT scores were attrib- uted to issues of reduced productivity, poor concentra- tion, and feeling frustrated. Although all SNOT subdomains improved subsequent to surgery, the largest improvement was observed in ENS symptoms and

Fig. 2. Changes in average pre- and postoperative Sino-Nasal Outcome Test subdomain scores, based on data obtained from Jiang et al., 17 Tam et al., 18 Jung et al., 19 and Saafan et al. 22 The maximum score column represents the maximum possible score for that particular subdomain. ENS 5 empty nose syndrome. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Clinical Outcomes The follow-up period varied widely (range 6–48 months). Most studies reported postintervention data based

Laryngoscope 125: July 2015

Leong: Surgical Interventions for Empty Nose Syndrome

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