Functional endoscopic sinus surgery (FESS) is the standard intervention after medical failure in managing chronic rhinosinusitis (CRS). Preservation and medial positioning of the middle turbinate (MT) during FESS are vital for sinus ventilation and surgical landmarks. However, postoperative lateralization of the MT occurs in 1–27% of cases, leading to ostiomeatal complex obstruction and recurrence requiring revision surgery. To prevent this, stabilization procedures such as Bolgerization and conchopexy suturing are employed. Bolgerization creates controlled synechiae by mucosal abrasion and scarring, while conchopexy sutures directly anchor the MT to the nasal septum. The aim of this study is to compare these two methods in preventing MT lateralization and maintaining postoperative sinonasal health. Aims and Objectives ● Aim: To compare the efficacy of conchopexy versus Bolgerization in preventing postoperative complications secondary to MT lateralization following FESS. ● Objectives: 1. To assess preoperative and postoperative perioperative sinus endoscopy (POSE) scores at 2 and 12 weeks. 2. To evaluate postoperative MT position after conchopexy. 3. To evaluate postoperative MT position after Bolgerization.

Study Design and Setting Randomized controlled surgical study in the Department of Otorhinolaryngology, Alluri Sitarama Raju Academy of Medical Sciences, Eluru, between July 2022 and 2024. Sample Size 70 patients fulfilling inclusion criteria. Inclusion Criteria • Age >14 years, both genders. • Indicated for FESS with or without septoplasty due to chronic rhinosinusitis, nasal polyposis, concha bullosa, or polypoidal MT changes. Exclusion Criteria • Bilateral ESS with previous MT damage/removal. • Malignancies. Preoperative Assessment History, clinical examination, hematological and biochemical investigations, CT scan (axial, coronal, sagittal views), and diagnostic nasal endoscopy. Surgical Techniques • Conchopexy: Fixation of MT to nasal septum using 4-0 absorbable suture. The needle passed through the MT and septum, tied securely avoiding nasal packing. • Bolgerization: Controlled synechiae creation by mucosal abrasion on anteroinferior MT and adjacent septal mucosa, followed by nasal packing for 10 days to encourage adherence. Postoperative Care All patients received systemic antibiotics for 10 days and were advised nasal douching. Follow-up Evaluations at 2nd and 12th postoperative weeks, with monthly reviews. POSE score and objective exams were performed. Chi-square test applied to evaluate significance between groups.

Table 1: Demographic Distribution Age group (years) Conchopexy N (%) Bolgerization N (%) Total N (%) 14–20 4 (11.4%) 5 (14.3%) 9 (12.9%) 21–30 11 (31.4%) 9 (25.7%) 20 (28.6%) 31–40 6 (17.1%) 7 (20.0%) 13 (18.6%) 41–50 8 (22.9%) 8 (22.9%) 16 (22.9%) 51–60 4 (11.4%) 5 (14.3%) 9 (12.9%) >60 2 (5.7%) 1 (2.9%) 3 (4.3%) Total 35 (100%) 35 (100%) 70 (100%) Table 2: Gender Distribution Gender Conchopexy N (%) Bolgerization N (%) Total N (%) Male 26 (74.3%) 20 (57.1%) 46 (65.7%) Female 9 (25.7%) 15 (42.9%) 24 (34.3%) Total 35 (100%) 35 (100%) 70 (100%) Table 3: Position of Middle Turbinate Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 29 (82.9%) 27 (77.1%) 56 (80%) Lateralised 6 (17.1%) 8 (22.9%) 14 (20%) Table 4: POSE Score (Mean ± SD) Group 2nd Week Score P Value (2nd Week) Conchopexy 2.1 ± 1.15 0.07 (not significant) Bolgerization 2.6 ± 1.51 Table 4: Status of Middle Meatus (MMA) at 2nd Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 18 (51.4%) 12 (34.2%) 30 (42.8%) Unhealthy 17 (48.6%) 23 (65.7%) 40 (57.1%) Table 5: Status of Middle Meatus (MMA) at 12th Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 21 (60%) 18 (51.4%) 39 (55.7%) Unhealthy 14 (40%) 17 (48.6%) 31 (44.3%) Table 6: Status of Anterior Ethmoid at 2nd Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 26 (74.2%) 20 (57.1%) 46 (65.7%) Unhealthy 9 (25.7%) 15 (42.8%) 24 (34.3%) Table 7: Status of Anterior Ethmoid at 12th Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 28 (80%) 23 (65.7%) 51 (72.9%) Unhealthy 7 (20%) 12 (34.3%) 19 (27.1%) Table 8: Status of Frontal Sinus at 2nd Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 28 (80%) 26 (74.2%) 54 (77.1%) Unhealthy 7 (20%) 9 (25.7%) 16 (22.8%) Table 9: Status of Frontal Sinus at 12th Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 31 (88.6%) 30 (85.7%) 61 (87.1%) Unhealthy 4 (11.4%) 5 (14.3%) 9 (12.9%) Table 10: Status of Sphenoid Sinus at 2nd Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 30 (81.7%) 25 (71.4%) 55 (78.5%) Unhealthy 5 (14.2%) 10 (28.5%) 15 (21.4%) Table 11: Status of Sphenoid Sinus at 12th Postoperative Week Status Conchopexy N (%) Bolgerization N (%) Total N (%) Normal 32 (91.4%) 29 (82.9%) 61 (87.1%) Unhealthy 3 (8.6%) 6 (17.1%) 9 (12.9%)

MT lateralization post-FESS can cause obstruction of osteomeatal complex, impairing ventilation and promoting disease recurrence. Multiple techniques exist to stabilize the MT during and after surgery. Conchopexy provides direct fixation to the septum using absorbable sutures, while Bolgerization induces synechiae by mucosal abrasion requiring nasal packing. This study reveals: ● Better MT positioning stability with conchopexy (82.9% normal) versus Bolgerization (77.1%). ● Middle meatus health was consistently superior in conchopexy patients at both early and late follow-ups. ● POSE scores showed no significant difference but slightly favored conchopexy. ● Results align with existing literature supporting conchopexy’s effectiveness and patient tolerance.

Both conchopexy and Bolgerization are effective in preventing MT lateralization, but conchopexy generally provides superior sinonasal health outcomes, improved middle meatus patency, and longer term benefits in sinus status. Conchopexy should be favored especially in patients with unstable or polypoidal MT. Larger studies with longer follow-up and subjective outcome measures are recommended. Ethical Clearance Approval obtained from ASRAMS BHR Ethics Committee, registration number M21007314034. Declaration The dissertation is original work by the author under the guidance of Dr. G V V S S S BALAKRISHNA RAJU and not submitted elsewhere. This document, containing the complete study from introduction through conclusion and all results tables, is ready for submission to appropriate ENT or Rhinology specialty journals for publication consideration.

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