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Fig. 8.6 Left side emphysema with normal-looking sclera. The right side picture is showing acute compartment
syndrome
A. Kanodia et al.
Fig. 8.7 NCCT PNS orbit (axial cut) is depicting the
dehiscence of lamina with prolapsed orbital fat. The
patient had history of trauma in childhood. Coronal cut is
showing extensive S/T/D in the left side of nasal cavity
and ethmoid sinus with pushed lamina papyracea
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suctioning effect [61]. The Stankiewicz pressure
test shows the movement of medial wall when
injury occurs to lamina papyracea and periorbita
[62]. In doubtful cases, fat oat test can be done.
Surgery can be completed by avoiding manipulation of prolapsed fat, gentle bipolar of fat obstructing the view and by avoid suctioning over it. Sinus
ostium should be widened enough to prevent
obstruction of the drainage pathway by prolapsed
fat. Surgeon should avoid tight nasal packing. The
patient should be advised not to blow nose
post-operative.
8.3.2.3 Injury toExtraocular Muscles
The right eye injury is more common than the left
eye probably due to right-handed surgeon’s
majority. The medial rectus is the most vulnerable extraocular muscle followed by inferior rectus and superior oblique. Strabismus and diplopia
are the leading clinical features. For contusions,
the treatment option is conservative treatment
(observation, antibiotics and steroids). If the
muscle is entrapped, the involved muscle should
be released. Gross divergent squint and absent
adduction are the sign of muscle transaction.
ENT surgeon may seek the advice of ophthalmologist. The various management options
include hang back suture (strabismus reduction),
botulinum toxin in contra muscle, the recession
of lateral rectus and transposition [63, 64].
8.3.2.4 Orbital Hematoma
The orbit is the close compartment. The Normal
intraocular pressure (IOP) is 10–20 mmHg.
Orbital hematoma is the post septal accumulation of blood. It accounts 0.05–0.5% of endoscopic surgery. The clinical features are
progressive proptosis, severe retrobulbar pain
and visual impairment. The signs are raised IOP
and alter pupillary reex. The intraoperative features are dilated xed pupil and bradycardia. It is
of two types, slow venous type and fast arterial
type. In the slow venous type, intra-orbital veins
are injured. Fast arterial type is mostly iatrogenic
and ethmoidal arteries are injured. Increased tension in globe can cause irreversible visual
impairment by inducing optic nerve stretching
and vascular compression. It can lead to perma-
nent blindness, if orbit is not decompressed
within 100–120 min. The standard treatment
policy for intraoperatively diagnosed orbital
hematoma is urgent orbital and optic nerve
decompression. When it is noticed in ward, the
surgical decision on the basis of intraocular pressure (IOP) is controversial. The medical management includes eye massaging, i/v mannitol,
i/v dexamethasone, and removal of nasal packing. If IOP is above 30–35mmHg and in patients
with IOP less than 20 with progressive proptosis,
severe retro-orbital pain, RAPD, cherry red macula and no retinal artery pulsation, the management option is urgent canthotomy and or
cantholysis in ward after local inltration.
Clamps are applied below and above lateral canthus for devascularization. Canthotomy is full
thickness incision on lateral canthus towards the
orbital rim. Cantholysis is the release of the lateral canthal ligament. Both procedures allow
anterior prolapse of orbit and it can reduce pressure by 10–15 mmHg. In progressive cases,
endoscopic or external orbital decompression
with multiple parallel incisions on periorbita to
suppress the effect of raised IOP [
surgeons performed canthal procedures and
orbital wall decompression in one go [65].
63, 64]. Some
8.3.2.5 Injury toOptic Nerve
The optic nerve runs in the lateral relationship of
the posterior ethmoid and sphenoid sinus. The
various predisposing factors for direct optic nerve
injury are the presence of Onodi cell, dehiscent
optic nerve canal and attachment of accessory
sphenoid septum with the optic canal [66].
Indirect damage can occur by compromising the
blood supply of optic nerve [63, 64]. It is seen in
orbital hematoma. Altered visual reex is the
sign of abnormality of function of optic nerve.
Pre-operative radiological assessment of the
course of optic nerve can minimize the chances
of injury. Intraoperative diagnosed optic nerve
injury should be managed by orbital and optic
nerve decompression. Post-operatively diagnosed cases are managed by mega doses of i/v
steroids (Methylprednisolone) and endoscopic
optic nerve decompression. The prognosis is very
poor even after all measures taken [67, 68].
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8.3.3 Intracranial Complications
8.3.3.1 CSF Fistula
Extended endoscopic approaches increase the
chances of CSF rhinorrhoea. Incidence varies from
0.2 to 16% in literature [69]. The patients with high
BMI, revision surgery and history of radiotherapy
are at more risk. It occurs due to damage to the
skull base and dura. Lateral lamella of the cribriform plate, ethmoid roof are the most common site
for CSF leak in FESS but in extended approaches,
pituitary fossa is the most common site. Chances
are increased by dehiscence in skull base by nasal
pathology like polyposis, tumour, etc. Inadequate
knowledge of radiology and undue manipulation of
structures attached with skull base like middle turbinate, superior turbinate, etc. can lead to iatrogenic skull base damage. It is safe to identify skull
base rst by posterior to anterior approach especially in revision cases or in cases with distorted
anatomy and if there is non-availability of navigation system. CSF rhinorrhoea is diagnosed by iden-
tifying the outow of watery uid from skull base.
The preventive measures for failed dural repair in
extended approaches is to avoid large surgical
defect, achieve adequate haemostasis before the
closure of defect with graft or ap, mucosa should
be replaced back over multilayer repair where sinus
obliteration is not planned, under vision nasal
packing and smooth extubation. Intraoperatively
diagnosed cases should be repaired in the same sitting by experienced surgeon. In post-operative
diagnosed cases, conservative management
includes i/v mannitol, stool softener, cough suppressants, head end elevation and restricted movement, etc. The use of lumber drain is based on the
effect of conservative management and surgeon’s
choice [69]. The site of leak in persistent cases
(1–2weeks of conservative management) can diagnose by either single imaging or by combining of
different modalities such as NCCT PNS orbit with
MR cisternography and intra-thecal or topical
application of uorescein dye (Fig.8.8) [70, 71].
Endoscopic multilayer closure of the defect is
Fig. 8.8 NCCT coronal cut- skull base is damaged at sphenoid sinus superior wall with pneumocephalus
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advised and naso-septal ap is most commonly
used to repair skull base defect [72].
8.3.3.2 Meningitis
This is a relatively rare intracranial complication and incidence varies from less than 1 to
10%. Extended endoscopic approaches have relatively higher risk of meningitis. Intraoperative
and post-operative CSF leak, perioperative lumber drain, prolong surgery, revision surgery in
short span, missed prophylactic antibiotics are
the common reason for meningitis in the postoperative period. Recent systemic review and
meta-analysis are not supporting the utility of
prophylactic lumber drain [73]. Sometimes, the
infection may spread along perivascular and
vascular or perineural spaces of the olfactory
bres. The meningitis trend is decreasing in the
recent past because of improvement in endoscopic surgical expertise, advance instruments,
better sealing materials and use of naso-septal
ap [74, 75].
Patient presents with severe headache, highgrade fever, nuchal rigidity, vomiting, cranial
nerve palsy, behavioural changes and seizures.
Sometime dry cough, mild headache and raised
TLC count is the only feature because of ongoing
post-surgical medications. In such cases, CSF
uid analysis is helpful in creating the diagnosis.
MR cisternography is good investigation in
doubtful cases of CSF leak. Treatment includes
targeted broad-spectrum antibiotics for 2weeks
and closure of the defect in persistent CSF rhinorrhoea patients.
8.3.3.3 Pneumocephalus
It occurs due to the presence of air in the cranial
cavity due to communication between the extracranial and intracranial cavity. It is rare complication of sinus surgery. It is more common in
patients with intraoperative and post-operative
CSF leak. It is also common with extended endoscopic approaches for the removal of intradural
lesions. Post-operative pneumocephalus is associated with greater risk of CSF leak and intracranial infection (Fig. 8.8). The mechanism is
believed to be ‘ball valve’ mechanism or ‘inverted
bottle’ mechanism. The patient can complain of
dizziness, visual alterations, confusion, behavioural and personality change. NCCT head is
good enough to pick air. Pneumocephalus
requires no treatment in asymptomatic patients.
Tension pneumocephalus requires prompt treatment, decompression of the aerocele followed by
the closure of the defect [76, 77].
8.4 Part DA: Biolms: Its
Composition, Detection
Methods andRole inHuman
Infections (Microbiologist
Aspect)
Biolms are dened as group of microbes in
which cells adhere to each other or substratum
irreversibly. Biolms can be present everywhere
in the environment. These biolms have the
potential to neutralize antibiotics and result in
prolonged treatment. Due to its resistant properties to antimicrobials and infections associated
with indwelling devices poses a problem for public health. Biolms formation is a multi-step process in which adaptation occurs during a series of
events under diverse nutritional and environmental conditions. Biolms have been found to be
involved in a wide variety of microbial infections
in the body such as bacterial vaginosis, urinary
tract infections, catheter infections, middle- ear
infections, the formation of dental plaque, gingivitis, coating lenses and endocarditis, infection in
cystic brosis, and infections of indwelling
devices. The biolms are signicantly resistant to
antibiotics and infection associated with them is
difcult to eradicate. Microbiological diagnosis
is important for the diagnosis of biolms. The
traditional methods like microscopy, culture
techniques are not always suited for the understanding of biolm science and are less sensitive
for detection. Therefore, there is need of newer
methods for the detection of biolms. The use of
bacteriophages, enzymes, surface coating agents,
pilicides and quorum sensing inhibitors are some
of the methods to control biolm formation. It is
challenging in medical science to eradicate infections related to biolm formation. This is due to
the fact that mature biolms exhibit tolerance
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towards immune response and antibiotics.
Further studies are required to know the mechanism of antibiotics resistance and their gene
expression biolm for better health care
improvement.
8.4.1 Introduction ofBiolms
Biolms are dened as group of microbes in
which cells adhere to each other or substratum
irreversibly. These sticked cells become embedded in extracellular polymeric substance (matrix)
produced by microbes themselves. Biolms can
be present everywhere in environment, industrial
and hospital settings and may form on living or
non-living surfaces [78]. The antibiotics and
human immune system normally cannot access
the bacterial biolms. These biolms have the
potential to neutralize antibiotics and result in
prolonged treatment. Due to its resistant properties to antimicrobials and infections related with
indwelling devices poses a problem for public
health. Biolm-forming capacity has been found
in number of bacterial species such as
Escherichia coli, Staphylococcus aureus,
Pseudomonas aeruginosa, Staphylococcus epidermidis, Enterobacter cloacae, Klebsiella
pneumonia [79].
8.4.2 Composition ofBiolms
Biolms are community of microbes that produce matrix (extracellular polymeric substances
(EPS) which consist of exopolysaccharides, pro-
teins and nucleic acids. Water (97%) is the major
component of biolm which is responsible for
the ow of nutrients inside the biolm matrix.
The other component of biolms are proteins
(<1–2%), DNA (<1%), polysaccharides (1–2%)
and RNA (<1%) [
80]. Various components of
biolms are shown in Table8.6.
8.4.3 Biolms Formation
The formation of biolm is a multi-step process
in which adaptation occurs during a series of
events under diverse conditions such as nutritional and environmental. During this process,
microbes transform from planktonic to the sessile
mode of growth. It is a complex process that
includes: (a) adherence to a surface (b) growth of
colonies (formation of micro-colony and threedimensional structure formation) (c) detachment
(dispersal) as shown in Fig.8.9 [81].
8.4.3.1 Attachment
When a microorganism cell reaches to surface,
the interface of solid–liquid can provide a suitable environment for microbes to attach and
grow. Hydrophilic, rough and coated surfaces
will provide better environmental attachment and
Table 8.6 Biolm composition
Constituents Percentages of matrix
Water Up to 97%
Microbial cells 2–5%
Polysaccharides 1–2%
Nucleic acid (RNA and DNA) <1–2%
Proteins <1–2%
Fig. 8.9 Showing steps
of biolms formation
STEP-1 STEP-2 STEP-3
Attachment
Growth
Detachment
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formation of biolm. Increase in temperature of
the water, ow velocity or nutrients, locomotor
organelle can further increase the attachment
process.
8.4.3.2 Growth ofColonies
After attachment, chemical signals lead to the
process of multiplication of bacteria in the biolms. The bacterial cell divisions occur within
the embedded matrix by using such signals which
results in micro-colony formation. After the stage
of micro-colony formation, expression of certain
biolms related genes helps in the formation of
matrix. The water-lled channel formation takes
place after EPS formation for the transport of
nutrients within the biolms. These water channels help in distributing nutrients and removing
waste materials from the micro-colonies of the
biolms.
8.4.3.3 Detachment
After micro-colonies formation, occasionally
under some mechanical stress bacteria are
detached from the communities into the environment. But in most cases, some microbes stop EPS
production and are detached into environment.
The detachment of new formed cells from growing cells or dispersion of biolm communities
occurs through a mechanism called quorum
sensing.
8.4.5 Role ofBiolms inHuman
Infections
Biolms have been found to be associated with
wide variety of microbial infections in the body.
Recently, it has been observed that biolms can
also impair wound healing by reducing topical
antimicrobial activity in treating wounds.
Association between various human infections
and biolms are shown in Table8.7 [84, 85].
8.4.6 Biolms Detection Methods
The biolms are signicantly resistant to antibiotic and infection associated with them is difcult to eradicate. Microbiological diagnosis is
important for the diagnosis of biolms. The traditional methods like microscopy, culture techniques are not always suited for the understanding
of biolm science and are less sensitive for detection. Therefore, there is need of newer methods
for the detection of biolms. Proper sonication of
indwelling devices from the patients can signicantly improve the detection of biolms. The
development of molecular and imaging techniques leads to a better understanding of biolm
science. Classical and newer biolm detection
methods are shown in Table8.8 [86].
8.4.4 Biolms andAntibiotic
Resistance
The key factors responsible for antimicrobial
resistance may vary among different sitting. The
following mechanisms have been explored for
high resistance nature of biolms: (1) low penetration of antibiotics, (2) neutralization by
enzymes, (3) heterogeneous functions, (4) cells
slow growth rate, (5) existence of persistent
cells, (6) biolm phenotype and (7) efux pump
and membrane alteration as shown in Fig.8.10
[82, 83].
8.4.7 Methods toControl Biolms [87]
(A) Pilicides—Small synthetic compounds
inhibit the synthesis of pili which further
inhibit binding and colonization on epithelial cells.
(B) Enzymes—The enzymes have the capability
to degrade the biolm matrix. Further, degradation of biolm results in the release of
components that are easily clear by immune
systems.
(C) Quorum sensing inhibitors—Using quorum
sensing inhibitors is another effective way in
control of biolm.
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Low Penetration of Antibiotics
Neutralization by Enzymes
Heterogeneous functions
Cell slow growth
A. Kanodia et al.
• The penetration or diffusion of antibiotics to biofilmis affected by EPS which act as physical
barrier
• Matrix may also acts as hindrance for Immune system cells
• The presence of neutralizing enzymes degrade or inactivate antibiotics
• These enzymes are proteins which confer resistance by mechanisms such as hydrolysis,
modification of antimicrobials by different biochemical reactions
• The biofilmsare heterogeneous nature both metabolically and structurally and both aerobic and
anaerobic process occur at the same time. So response against antibiotics may be different in
different areas of the biofilms.
• On surface of biofilm there is a high level of activity of antibiotics while inside the biofilms,
slow or absent growth reduces the sensitivity to antimicrobials
• This process occurs due to limited availability of nutrients which confer resistance to antibiotics.
In case of biofilma gradient of nutrients resulting in metabolically active cell (periphery or
surface layer) and inactive cells (within its interior) . Antibiotics like penicillin and ampicillin
only attack the cells when they are growing. However, other antibiotics such as β-lactams,
aminoglycosides, cephalosporin and fluoroquinolonesattack cells in stationary phase
• In stationary phase, the density of bacterial cells raised to maximum indicating the role of
Existence of Persistent Cells
Biofilm Phenotype
Efflux pump and membrane
alteration
persistent cells for survival
• There are certain evidences for the existence of persistent cells in biofilm: a) Presence of a
biphasic dimension in biofilms b) presence of gene description function as a regulation, c)
bacteriostaticantimicrobial contribute to the growth of persistent cell d) reshaping of biofilm
into original form when the antimicrobial therapy is withdrawn
• The bacteria produce secondary metabolites during biofilmformation.Thesemetabolites acts as
signaling molecules, which enhances biofilm formation
• Biofilm phenotype is regarded as group of cells that confer no response to antimicrobials
treatment
• Efflux pumps show resistant to multiple antibiotics thus reducing these antibiotics
concentration,example-over expression of the efflux pumps have been observed in P.
aeruginosa biofilms
• Mutation in porinsencoding genes can result in low permeability for the passage of hydrophobic
molecules
• The differential expression of porins coding genes, occur in biofilm, leading to antibiotic resistance
Fig. 8.10 Showing factors responsible for antibiotic resistance in biolms
(D) Surface Coatings—Another effective way
8.4.8 Future Aspects ofBiolm
for the eradication of biolm is coating the
indwelling devices with antimicrobials.
(E) Bacteriophages—It has been observed that
bacteriophages have the ability to inhibit or
reduce formation of biolm. Phage cocktail
can also be used for removal of biolm.
It is challenging to eradicate infections related to
biolm formation in medical science. This is due
to the fact the mature biolms exhibit tolerance
towards immune response and antibiotics.
Further studies are required to know the mecha-
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Table 8.7
Condition Salient features
Acute wound Biolm formation in wounds has been investigated in-vivo model (murine and porcine) for S.
Chronic
wound
Infectious
kidney stones
Bacterial
endocarditis
Infections in
Cystic
brosis
Other Biolm
Diseases
Otitis media
with effusion
Acute
osteomyelitis
Table 8.8 Detection methods of biolm
Classical methods Newer methods
Microtiter plate
assay
Tube adherence
method
Congo red agar
method
Biolm bioreactor PCR techniques
Biolm Ring test Spectrometry
Showing association between various human infections and biolms
aureus, P. aeruginosa and Streptococcus biolm
In chronic wound, antibiotic treatment is considered to be effective in initial stages but after
formation of biolm, antibiotic therapy is least effective. Because biolm can be up to 1000 times
resistant to antimicrobials
The interaction between bacteria and mineral substances derived from urine results in formation of
kidney stones, which are responsible for urinary tract infections. This result in the formation of
biolm
The interaction between bacteria and host components lead to formation of biolm which is known
as vegetation. This vegetation can cause disease by different mechanisms: Disrupting the function
of valve by creating leakage, turbulence, causes bloodstream infections or break down the
vegetation which is then carried into the circulation (embolization)
These patients are most commonly infected with P. aeruginosa. The permanent infections in such
cases with P. aeruginosa biolm take place which last for the rest of the patient’s life
• The patient speech development and learning capability will be affected
• Necrosed bone produced favourable conditions for biolm development
are believed to be due to the formation and per-
Photobioreactor
sistence of biolms [
88, 89]. These biolms are
highly resistant to treatment with antimicrobials
Ultrasound
and are capable of shedding bacteria into the
bloodstream which leads to recurrent bouts of
Sequencing Technologies
infection [90]. It has been noted that the presence
of bacterial biolms can be the reason for some
forms of recalcitrant chronic rhinosinusitis.
Confocal laser scanning
microscopy
Fluorescent in situ hybridization
Nuclear magnetic resonance
imaging
Biolms that form on the surface of airway
mucosa are known as mucosal biolms. These
are different from those that form on inert devices
because these have to overcome the normal airway mucociliary clearance [
91]. Inadequate
doses of antibiotics for the treatment of rhinosinism of antibiotics resistance and their gene
expression biolm. For better health care
improvement, better understanding is needed for
the development of novel, effective control strategies against biolm.
nusitis can lead to biolm formations and chronic
infections. The most common cause of CRS
refractory to medical treatment is the opportunis-
tic infection with biolm-forming Pseudomonas
aeruginosa. Also implicated are Staphylococcus
aureus, Streptococcus pneumoniae, Haemophilus
inuenzae and Moraxella catarrhalis [92, 93].
8.5 Part DB: Biolms: Surgeon’s
Aspect
Fungal elements are also seen in biolms.
Candida albicans is the most common cause of
biolm formation among pathogenic fungi [94].
Biolms are increasingly recognized as a cause
for persistent otorhinolaryngologic infections.
About 75% of the microbial infections in humans
In children suffering from chronic otitis media
and CRS, adenoidectomy is considered benecial. Biolm covered adenoids in nasopharynx of
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children with chronic rhinosinusitis, biolms act
as reservoir for reinfection. 95% of the adenoids
and 70% of tonsils removed from children suffering from CRS have been found to be covered
with biolms.
It is a potential cause or persistent symptoms
in some patients after ESS [95]. Frontal recess
stents, stenting for choanal atresia, intranasal
tubes are highly likely to be covered with biolms and this can worsen the prognosis of
surgery.
8.5.1 Treatment
Bacteria associated with biolms behave differently from platonic bacteria, particularly in terms
of antibiotic sensitivity. Biolm cells are about
500 times more resistant to antimicrobial agents
[87]. The structure of the biolm along with the
extracellular matrix prevents the drug from
reaching the cells. Systemic treatment may
require very high doses of antibiotics which may
be intolerable and may not be effective at all.
Genetic resistance to antibiotics could be due
to decreased penetration, decreased metabolic
activity of biolms, increase in the number of
efux pumps and presence of different subpopulations of bacteria within a biolm [96].
Interfering in the various stages of biolm formation like the interruption of quorum sensing or
the genes involved in cellular attachment can be
used as a strategy to inhibit biolm formation.
Variety of techniques has been evaluated for
managing and treating biolms including surgery, topical antimicrobials and adjuvant therapies. Newer treatments are aimed at disrupting
the life cycle of biolms, preventing their attachment on to the surfaces and to disrupt the quorum
sensing. With topical treatment, there are three
strategies for eradication of biolms.
1. Specic antibiotics against the causative
microorganism.
2. Mechanical force for the detachment of the
biolm from the surface. E.g Surfactants, irri-
gation, surgery.
3. Quorum sensing inhibitors shift the bacterial
phenotype from sessile to platonic form.
Various antibiotics have been tested for topi-
cal treatment of biolms.
• Mupirocin has been found effective against the
Staphylococcus aureus biolms. It is effective
because of its broad spectrum of action.
• Honey was effective against S. aureus and P.
aeruginosa biolms invitro. It was found to
eradicate 73% of MRSA biolms and 91% of
pseudomonas biolms [97].
Surfactants break up the biolm and allow the
bacteria to be removed by irrigation.
• Baby shampoo has been used as a chemical
surfactant to disrupt biolms [98].
• Citric acid/zwitterionic surfactant solution by
means of pressurized jet lavage is effective in
breaking up biolms invitro [99].
• Surgical ventilation of the affected sinus helps
against biolm infections. It increases the
oxygen tension and mechanically disrupts the
biolms [100].
Quorum sensing inhibitors increase the suscep-
tibility of the biolms to antibiotics and phagocytosis. Systemic long-term low dose macrolide
therapy has been found to decrease the virulence
of the bacteria and prevents the formation of biolms [101]. For medical indwelling devices, ion
bombarded silicone ventilation tubes have been
found to be better than other silicone tubes.
Preventive Measures:
Biolm can be prevented by vaccination
against organisms that can cause chronic infections like pneumococci. Antibiotic prophylaxis
and aggressive antibiotic therapy can prevent biolm formation.
Newer Advances:
The detection of intercellular signalling sys-
tem, lasR-lasI and rhlR-rhlI, involved in the
development of P. aeruginosa biolms, indicate
signal manipulation as a possible target to control
biolms [102].
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8.6 Part E: Empty Sinus
Syndrome
Empty Nose syndrome (ENS) is a distinct clinical entity, which has been highlighted, in the
recent few years because of the increasing incidence of Turbinate Surgeries. Since there are no
set diagnostic criteria, so the diagnosis of these
patients is based on combination of clinical
examination, standardized questionnaires, CT
scan and few objective tests. Treatment mainly
consists of medical measures, with the surgical
options only to be offered once the medical management fails and psychosomatic component is
ruled out. In ideally selected candidates, surgery
can provide extremely satisfying results by augmenting the volume of the lost tissues of the turbinates, thus channelling the airow patterns.
Research is underway worldwide to restore the
function of the turbinates by injecting PlateletRich plasma, Platelet-rich lipotransfer and extracellular matrix components, which have shown
initial promising results.
8.6.1 Introduction
Eugene Kern from Mayo clinic rst described
this entity in 1994. Empty Nose Syndrome (ENS)
is an iatrogenic disorder characterized by the
presence of paradoxical nasal obstruction, despite
an objectively visible wide nasal cavity. It occurs
few months to years after partial/total resection
of the turbinates and sometimes even after turbinate surface cauterization. The basic pathology
of this condition stems from changes in nasal
physiology after volume reduction of turbinates.
Exact incidence is not known, because of the
paucity of literature and poor reporting of this
entity.
There are various subtypes of ENS described
by Houser SM [103], depending on the turbinate
tissue, which is involved.
(A) ENS—IT type (Inferior Turbinate), which
occurs after various surgeries for Inferior
turbinate (IT) reduction (Fig.8.11a).
(B) ENS—MT type (Middle Turbinate)—
Symptoms occur after excessive resection of
the middle turbinate (MT). In addition to
paradoxical nasal obstruction, patients have
pain on breathing.
(C) ENS-both—Refers to patients who have
resection of both IT and MT tissues and lastly.
(D) ENS-Type—Patients who seem to have ade-
quate normal tissue volume of the turbinate,
yet they have ENS like symptoms. This is
because of mucosal changes, which have
occurred because of surface cauterization
(Fig.8.11b).
Fig. 8.11 (a) ENS is IT TYPE and (b) ENS is TYPE 1B
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