The middle and superior turbinates should gently be lateralized after a complete frontosphenoethmoid-ectomy to open up the olfactory cleft. Atraumatic lateralization of the turbinates is only possible after making space for them (Fig. 5.87 a-d). This reduces the mucosa-mucosa contact in this area and allows better access for topical nasal steroids.
It is difficult to resist the temptation to remove or debulk polyps medial to the middle turbinate, but it is best to preserve this mucosa. A course of preoperative steroids will help reduce the size of the polyps. Only remove polyps that come from the posterior ethmoid cells under the superior turbinate and not polyps that are based on the septum or the middle turbinate.
If the surgeon displaces the middle turbinate in this way, the surgeon should ensure that the middle meatal antrostomy is undertaken such that it lies at a level below the inferior edge of the middle turbinate, so that if the middle turbinate lateralizes, the maxillary ostium can still drain (Fig.5.88a, b) and it is possible to visualize the maxillary sinusotomy and the frontal recess as well as the ethmoids with a 45° endoscope. The middle turbinate should remain relatively stable as long as it is only gently lateralized and the base or inferior horizontal component of the ground lamella is preserved. Even when it is very mobile we would prefer for it to lateralize rather than for it to adhere to the septum and run the risk of making olfaction worse.
When the olfactory cleft is opened, even large polyps medial to the middle turbinate resolve, so do not be worried about leaving them behind (Fig. 5.89 a-c). Note that no polyps were removed from the middle turbi-nate in order to preserve olfactory mucosa. It is easy to remove them, but not easy to put back the olfactory epithelium that is removed with them! 7, 8
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