Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent inflammatory disorder of the nasal and paranasal mucosa, characterized by nasal obstruction, rhinorrhea, facial pressure, and hyposmia, with symptoms persisting for more than 12 weeks despite medical management (1). Affecting approximately 2–4% of the general population, CRSwNP significantly impacts quality of life and poses a substantial socioeconomic burden due to its recurrent nature (2,3).

Functional endoscopic sinus surgery (FESS) has become the standard operative intervention for patients with medically refractory CRSwNP, aiming to restore sinus ventilation and mucociliary clearance (4). However, despite advancements in surgical technique, recurrence of nasal polyps remains a notable challenge, with reported rates ranging from 20% to 60% depending on disease severity and follow-up duration (5,6).

The middle turbinate (MT) plays a crucial anatomical and functional role within the nasal cavity, serving as an important landmark during FESS and contributing to airflow regulation and olfactory function (7). While preserving the MT is generally preferred, partial resection may be necessary in cases of anatomical variations, polypoid changes, or obstructive pathology to improve surgical access and reduce recurrence (8). Nonetheless, concerns regarding complications such as empty nose syndrome, synechiae, and olfactory disturbances have led to ongoing debate regarding the benefits and risks of middle turbinate resection (9,10).

This study aims to evaluate the impact of partial middle turbinate resection (PMTR) on the postoperative recurrence rates in patients undergoing FESS for CRSwNP. Through a prospective observational design, the study seeks to provide evidence-based guidance on the role of PMTR in improving long-term surgical outcomes.

This prospective observational study was conducted at the Department of Otorhinolaryngology, BKL Walawalkar Medical College, Sawarde, District Ratnagiri, over a period of five years, from January 2018 to December 2023. The study aimed to evaluate the impact of partial middle turbinate resection (PMTR) on recurrence rates following functional endoscopic sinus surgery (FESS) in patients diagnosed with chronic rhinosinusitis with nasal polyps (CRSwNP).

Study Population:

A total of 100 adult patients (aged 18–65 years) with a confirmed diagnosis of CRSwNP based on clinical presentation, endoscopic findings, and computed tomography (CT) imaging (Lund-Mackay score ≥4) were enrolled. Patients with a history of previous sinus surgery, sinonasal malignancy, allergic fungal sinusitis, or immunodeficiency disorders were excluded.

Study Design and Grouping:

Eligible patients were randomly assigned into two groups using a computer-generated randomization method:

• Group A (n=50): Underwent standard FESS without partial middle turbinate resection.
• Group B (n=50): Underwent FESS with partial middle turbinate resection on the affected side.

Surgical Procedure:

All surgeries were performed under general anesthesia using a standard endoscopic approach. The extent of sinus clearance was determined based on disease severity. In Group B, partial resection of the middle turbinate was performed to enhance access and visibility while preserving its anterior and superior attachments to avoid destabilization.

Postoperative Care and Follow-up:

Postoperative care included nasal saline irrigation, intranasal corticosteroid sprays, and short-term antibiotics. Patients were followed at regular intervals—1 month, 6 months, 1 year, 3 years, and 5 years post-surgery. Clinical evaluation was done using endoscopic assessment (Lund-Kennedy score) and symptom scoring via the 22-item Sino-Nasal Outcome Test (SNOT-22).

Outcome Measures:

The primary outcome was the recurrence of nasal polyps, defined as the reappearance of endoscopically visible polyps requiring revision surgery or medical treatment intensification. Secondary outcomes included symptom improvement and complication rates between the two groups.

Statistical Analysis:

Data were compiled using Microsoft Excel and analyzed with SPSS version 25.0. Quantitative variables were compared using the Student’s t-test, and categorical variables were assessed using the chi-square test. A p-value of <0.05 was considered statistically significant.

A total of 100 patients diagnosed with chronic rhinosinusitis with nasal polyps were included in the study and followed up for a period of 5 years. Group A (standard FESS without PMTR) and Group B (FESS with PMTR) each consisted of 50 patients. The demographic characteristics, such as age and gender distribution, were comparable between both groups.

At the 5-year follow-up, the recurrence of nasal polyps was significantly higher in Group A compared to Group B. In Group A, 19 patients (38%) experienced recurrence, whereas in Group B, recurrence was noted in only 11 patients (22%). The difference was statistically significant (p = 0.041).

SNOT-22 scores were used to assess patient-reported symptom improvement. At baseline, the mean SNOT-22 score was similar in both groups (Group A: 55.7 ± 3.9; Group B: 56.3 ± 4.2). After 5 years, Group B reported a greater reduction in symptom burden (mean score: 18.7 ± 2.8) compared to Group A (mean score: 27.4 ± 3.2), which was also statistically significant (p < 0.05).

The Lund-Kennedy endoscopic score, evaluating nasal polyp visibility, edema, and discharge, also showed more favorable outcomes in Group B, with a mean postoperative score of 2.3 ± 1.1, compared to 3.9 ± 1.5 in Group A (p = 0.032).

No major complications such as cerebrospinal fluid leak, significant bleeding, or synechiae were observed in either group during the postoperative period.

Table 1: Comparison of Postoperative Outcomes Between Group A and Group B at 5-Year Follow-Up

(Table 1) illustrates the comparison of key outcome measures between both patient groups over a 5-year period. The data suggest a statistically significant benefit of PMTR in reducing recurrence and improving symptom scores.

The findings of this prospective study suggest that partial resection of the middle turbinate (PMTR) during functional endoscopic sinus surgery (FESS) contributes to a significant reduction in the long-term recurrence of nasal polyps in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). Patients who underwent PMTR demonstrated better endoscopic scores, improved symptom control, and reduced need for revision interventions, without an increased rate of postoperative complications.

Recurrence in CRSwNP is a multifactorial process influenced by underlying inflammation, mucociliary dysfunction, and residual disease burden post-surgery (1). Traditional FESS techniques have focused on preserving anatomical structures like the middle turbinate to avoid complications such as empty nose syndrome or olfactory impairment (2,3). However, anatomical variations, polyp burden, and compromised visibility during surgery may necessitate partial resection to ensure adequate disease clearance and improve access to the ethmoid and frontal sinuses (4,5).

Several studies have supported the rationale for PMTR in selected cases. Yan et al. reported that patients undergoing PMTR had a lower recurrence rate compared to those with turbinate preservation (6). Similarly, Thornton and Dutton emphasized that selective resection enhances surgical field visualization and reduces obstruction of drainage pathways, potentially lowering recurrence (7). The current study aligns with these findings, demonstrating a 16% absolute reduction in recurrence at 5 years in the PMTR group.

Importantly, the safety of PMTR has been a concern among surgeons. However, our study showed no significant complications such as cerebrospinal fluid leaks, excessive bleeding, or adhesions in either group, consistent with the findings of Stammberger et al., who reported that when performed with anatomical respect, PMTR does not compromise nasal physiology (8). Moreover, the preserved anterior and superior attachments of the middle turbinate in our protocol likely contributed to the stable outcomes observed.

Symptom improvement was objectively measured using the SNOT-22 score, with the PMTR group showing statistically greater reductions. This aligns with the work of Smith et al., who correlated improved endoscopic and symptom scores with more complete surgical removal of inflammatory tissues (9). Additionally, the endoscopic Lund-Kennedy score reflected better mucosal healing in the PMTR group, corroborating reports by Fokkens et al. and Lee et al. that reduced mucosal burden post-surgery promotes sustained disease control (10,11).

A point of contention in earlier studies was the risk of synechiae and altered airflow dynamics following turbinate manipulation (12). However, with meticulous surgical technique and appropriate postoperative care, including debridement and corticosteroid therapy, such risks can be minimized (13). In our study, structured follow-up and consistent medical management protocols likely contributed to the favorable outcomes seen in both groups.

From a long-term perspective, improved surgical access due to PMTR may facilitate better distribution of postoperative topical therapies, further reducing recurrence (14). Moreover, patient satisfaction and quality of life improvements were higher in the PMTR group, consistent with the recommendations from the EPOS 2020 guidelines, which support tailored surgical approaches based on disease extent and anatomical variation (15).

Limitations of this study include its single-center design and relatively small sample size, which may affect the generalizability of results. However, the prospective design and extended follow-up add to the robustness of the findings. Future multi-center randomized trials are recommended to validate the benefits of PMTR and establish guidelines for its appropriate use.

Partial middle turbinate resection (PMTR), when incorporated during functional endoscopic sinus surgery, significantly reduces the recurrence of nasal polyps and improves patient-reported outcomes in chronic rhinosinusitis with nasal polyps. The procedure is safe and effective, offering better symptom relief and mucosal healing without increasing postoperative complications. PMTR should be considered as a valuable adjunct in appropriately selected cases to optimize long-term surgical success.

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