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The inferior turbinate is an important structure serving a vital role in nasal physiology. However, inferior turbinate enlargement can lead to decreased nasal airflow and a sensation of nasal obstruction. Chronic nasal obstruction can substantially affect quality of life, productivity, and finances, and when medical therapies fail, surgical management is often recommended. Many techniques for inferior turbinate reduction exist, including outfracturing, submucosal soft tissue reduction (ie, electrocautery, radiofrequency coblation, and powered microdebrider), submucosal bone removal, argon plasma coagulation, laser reduction, partial turbinectomy, and total turbinectomy. These techniques have demonstrated varied long-term results, and there remains a lack of consensus as to the optimal surgical technique. However, given the important role the inferior turbinates play in nasal physiology, many contemporary surgeons aim to strike a balance between adequate tissue resection for symptom improvement and preservation of functional turbinate tissue and its contribution to normal nasal physiology.
The inferior turbinate is an important structure, serving a vital role in nasal physiology. It has many functions, including the filtration, warming, and humidification of inspired air, in addition to the regulation of nasal airflow. However, inferior turbinate enlargement, due to hypertrophy or edema, can lead to decreased nasal airflow, and subsequently, a sensation of nasal obstruction. Chronic nasal obstruction can substantially affect quality of life, productivity, and finances.
A number of medical therapies exist to treat patients with nasal obstruction secondary to enlarged inferior turbinates; however, when these medical therapies fail, surgical management is often recommended. The focus of this article is a wide variety of surgical techniques that have been described to reduce the size of enlarged inferior turbinates when medical management has yielded unsatisfactory results.
Indications, patient selection, and workup
Inferior turbinate reduction is one of the most commonly performed sinonasal surgical procedure, and the most common indication for turbinate reduction is nasal obstruction due to inferior turbinate enlargement. In addition to relief of nasal obstruction, inferior turbinate reduction may also play a role in the treatment of adult and pediatric sleep-disordered breathing.
Improved objective outcomes and quality of life after adenotonsillectomy with inferior turbinate reduction in pediatric obstructive sleep apnea with inferior turbinate hypertrophy.
Radiofrequency treatment of turbinate hypertrophy in subjects using continuous positive airway pressure: A randomized, double-blind, placebo-controlled clinical pilot trial.
There are numerous possible etiologies for inferior turbinate enlargement. This includes physiological, anatomical, or pathophysiological causes, such as allergic, vasomotor, and hormonal rhinitis, as well as systemic inflammatory diseases. As such, an assessment for allergic and other systemic etiologies is a crucial component of a comprehensive medical history of any patient being evaluated for nasal obstruction. Physical examination should include anterior rhinoscopy and nasal endoscopy, before and after nasal decongestion, to differentiate between possible bony and soft tissue contributions to turbinate enlargement and the patient׳s symptoms. Before considering surgical intervention, treatment typically consists of medical therapy, which may include topical nasal steroids, antihistamines, and nasal saline irrigations.
The inferior turbinate is composed of a central bony portion that projects from the medial aspect of the maxillary and palatine bones at varying angles, and is surrounded medially, laterally, and inferiorly by a layer of soft tissue. This soft tissue layer, which is thickest along the medial aspect of inferior turbinate, is composed of erectile tissue with seromucinous glands and venous sinusoids and is covered by pseudostratified ciliated columnar epithelium.
The venous sinusoids play a significant role in the regulation of mucosal thickness and are controlled by sympathetically innervated arterial resistance vessels. The inferior turbinate has a rich, variable blood supply, mainly provided by the posteriorly located inferior turbinate branch of the posterior lateral nasal artery, originating from the sphenopalatine artery.
The inferior turbinates play an important role in nasal physiology. By increasing the mucosal surface area in the nasal cavity, the turbinates serve to warm and humidify inspired air, and thus facilitate pulmonary alveolar gas exchange. Furthermore, the orientation and shape of the turbinates streamline inspired air posteriorly, while providing sufficient resistance to decrease airflow velocity and change it from a laminar to a transitional pattern.
This increase in turbulence aids in the filtration function of the nasal cavity, by allowing for the trapping of inspired debris in the mucus layer of the nasal epithelium, which then serves to remove the debris from the nasal cavity through mucociliary clearance. When nasal resistance is abnormally low (eg, owing to excessive inferior turbinate surgical reduction), the altered airflow and resistance patterns may lead to paradoxical subjective complaints of nasal obstruction, known as “empty nose syndrome.”
Most people experience irregularly alternating asymmetric airflow through the nose, commonly referred to as “the nasal cycle,” due to alternating engorgement within the nasal erectile mucosa, and especially that of the inferior turbinates. At any given time, one side of the nasal passages is typically more congested with a reduced amount of secretions, whereas the contralateral nasal cavity is more widely patent but has increased secretions from serous and mucus glands. Despite the constant fluctuation of each individual turbinate size and ipsilateral airway resistance, the total resistance of the whole nasal airway has been noted to be constant, as described by Kayser in 1895.
Numerous surgical techniques have been described for the treatment of inferior turbinate hypertrophy, and there remains a lack of consensus as to the optimal technique. These surgical techniques differ in the amount and type of tissue resection and preservation (Figure 1). As our understanding of nasal physiology has grown, surgical techniques have also evolved with the aim to achieve both maximal symptom improvement and preservation of function. Furthermore, in the current age of rising health care costs, some of the turbinate procedures described are now performed in the office setting using local and topical analgesia. The following techniques are discussed in a sequential order, starting with techniques that generally involve the least amount of tissue removal and progressing toward techniques with more tissue resection.
Figure 1Surgical techniques for inferior turbinate reduction differ in the amount and type of tissue resected. The maxillary sinus is labeled with an asterisk for orientation purposes, and the tissue typically removed for each technique is demarcated. (A) Lateralization of the inferior turbinate with outfracture. (B) Submucosal soft tissue reduction (ie, submucosal electrocautery, radiofrequency coblation, and microdebrider). (C) Resection of the inferior turbinate bone. (D) Resection of the inferior turbinate bone and lateral mucosa. (E) Partial mucosal and soft tissue resection or ablation (ie, laser turbinectomy). (F) Total turbinectomy.
Lateralization of the inferior turbinate involves an outfracturing of the turbinate bone to decrease the angle with which the inferior turbinate bone projects from the maxillary and palatine bones along the lateral nasal wall (Figures 1A and 2).
This procedure typically begins with an infracture of the turbinate bone by placing a Boies or Goldman elevator lateral to the inferior turbinate in the inferior meatus. Force is then directed medially and superiorly in an attempt to avoid a greenstick fracture, but rather create a fracture line near the bony attachment to the lateral nasal wall (Figure 2A and B). This, in turn helps to achieve maximal lateralization when the inferior turbinate is subsequently outfractured by using the elevator to direct force inferiorly and laterally along the turbinate׳s attachment site to the lateral nasal wall (Figure 2C). Lateralization of the inferior turbinate is generally not considered sufficient as a stand-alone procedure for the management of significant turbinate hypertrophy, but it can be helpful when used in conjunction with other turbinate reduction procedures.
Figure 2Lateralization of the inferior turbinate begins with an infracture of the turbinate bone toward the nasal septum (A) to create a fracture line near the attachment to the lateral nasal wall (B). This is followed by a lateral outfracture away from the nasal septum (C).
The submucosal soft tissue of the inferior turbinate can be reduced using a variety of methods, including direct tissue resection, and various thermal techniques that produce submucosal injury (Figures 1B and 3). This leads to submucosal fibrosis and contracture, with obliteration of the venous sinusoids, and a reduction of the erectile properties of the submucosal tissue.
Figure 3Submucosal soft tissue reduction targets the erectile tissue under the epithelium. This can be accomplished using a similar submucosal tunnel using electrocautery (A), radiofrequency coblation (B), or a powered microdebrider with a specialized flat tip elevator (C).
Monopolar electrocautery and bipolar electrocautery can be used to produce submucosal thermal injury. This technique involves the use of a single needle electrode (Figure 3A), or bipolar forceps with needle tips. After the administration of local anesthetic, the electrode can be pressed against the head (anterior portion) of the inferior turbinate and activated for a short period to produce a devascularized zone. The needle electrode is then inserted into the submucosa through this zone and advanced toward the tail of the inferior turbinate while taking care to stay close to the turbinate bone. The electrocautery is then activated as the needle is slowly withdrawn to inflict the thermal injury near the tip of the electrode. Preference regarding the power and duration of electrocautery, as well as the optimal number of passes, is surgeon dependent.
Radiofrequency tissue reduction involves the direct application of a high-frequency current to the targeted tissue, leading to submucosal injury from friction between ions. This technique differs from the electrocautery technique in several ways; although it still generates enough thermal energy to cause the desired submucosal injury, the maximal temperature generated (typically less than 85°C), and dissipation of the heat within the tissue, is significantly lower than that with electrocautery (which can reach up to 800°C).
Comparison of the effectiveness and safety of radiofrequency turbinoplasty and traditional surgical technique in treatment of inferior turbinate hypertrophy.
This is one of the reasons the technique has become popular in the office setting under local anesthesia. There are numerous radiofrequency devices designed with both monopolar and bipolar delivery of energy. Much like the electrocautery technique, the turbinate is first infiltrated with local anesthetic, which can expand the submucosal tissue making the procedure easier to perform. The wand tip is then coated in saline gel or another conductive media and activated at the head of the turbinate to produce a devascularized zone. The wand is then inserted through this zone and advanced toward the tail of the turbinate submucosally (Figure 3B). It is then activated for a short period (eg, 10 seconds), and then partly withdrawn and activated again. As with submucosal electrocautery, preference regarding the power and duration of coblation, and the optimal number of passes, is surgeon dependent. Typically, settings of 75°C-85°C, 10-15 W, and 300-500 J, or a coblation setting of 4-5, have been reported in the literature depending on the system used.
Powered submucosal turbinate reduction
Similar to the submucosal thermal techniques described, the intention of powered submucosal resection is to reduce the amount of submucosal erectile tissue, while leaving the overlying epithelium unharmed. With the recent advent of a smaller (2.0-2.9 mm), specifically designed inferior turbinate microdebrider blade, with an incorporated tip elevator, this procedure has been made easier (Figure 3C). The inferior turbinate is first infiltrated with local anesthetic, typically with epinephrine, to limit hemorrhage and expand the targeted submucosal soft tissue. The tip of the specialized microdebrider blade, or a scalpel, is then used to perform a stab incision in the head of the inferior turbinate (Figure 4A). The microdebrider blade is then advanced (with the cutting surface facing laterally) and used to create a submucosal pocket on the inferomedial surface of the turbinate bone, using the flat tip as an elevator (Figure 4B). If a specialized turbinate blade is not available, the flap dissection can be performed using a Cottle or Freer elevator.
The microdebrider blade is then rotated toward the submucosal soft tissue and activated, typically at speeds of up to 3,000 rpm in oscillating mode. Care must be taken to avoid flap perforation, while targeting the anterior and inferomedial submucosal soft tissue that contributes most significantly to nasal airflow obstruction.
Submucosal resection can be carried all the way to the tail of the turbinate posteriorly; however, this does carry an increased risk of bleeding owing to injury to vascular contributions from the posterior lateral nasal and sphenopalatine arteries.
Figure 4The microdebrider can be used to reduce submucosal soft tissue. The flat tip is first used to make an incision in the head of inferior turbinate (A) and then to create a submucosal pocket where the microdebrider is activated (B).
Submucosal resection of the inferior turbinate bone is another technique that can be especially effective in patients with enlarged turbinate bone, which can be a major contributor to turbinate enlargement (Figures 1C and 5). Depending on the thickness of the inferior turbinate bone, it may be possible to resect a portion of it using the submucosal powered microdebrider technique previously described, with the blade turned laterally against the turbinate bone. Alternatively, a more comprehensive resection of the bone can be performed using a more traditional submucosal dissection. For this technique, a larger anterior incision is made and extended posteriorly along the inferior edge of the turbinate (Figure 5A). A Cottle or Freer elevator is then used to raise a mucoperiosteal flap medially off the underlying turbinate bone (Figure 5B). Another mucoperiosteal flap can then be raised off the lateral surface of the turbinate bone, and the 2 flaps can be apposed after the bone is resected with a through-cutting instrument (Figure 5C and D). Alternatively, as described by Mabry,
the lateral turbinate mucosa can be resected along with the turbinate bone, and the remaining flap of medial and inferior mucosal tissue can be rolled up on itself, from medial to lateral, to form a neoturbinate with 2 apposing inverted raw surfaces, and an external mucosal surface (Figure 1D).
recently described the use of an ultrasonic bone aspirator to remove inferior turbinate bone. This device uses ultrasonic waves to emulsify bone, with concurrent irrigation and microsuction of bone particles producing a clean surgical field; this reportedly enables removal of the inferior turbinate bone without thermal or mechanical injury to the surrounding soft tissue or mucosa.
Figure 5Submucosal bone resection begins with an anterior incision that is extended posteriorly along the inferior edge of the turbinate (A). Medial and lateral mucoperiosteal flaps are then raised (B), and the underlying bone is resected leaving the 2 flaps (C). The raw surfaces of the flaps are then placed together and lateralized (D).
Numerous mucosal sacrificing techniques have been reported describing different degrees of inferior turbinate resection. However, prevailing knowledge of the important role that the inferior turbinate and its epithelium play in nasal physiology has led many surgeons to steer away from more aggressive full-thickness resection techniques and those involving extensive resection of the turbinate epithelium.
Partial turbinectomy
Anterior turbinectomy removes a small portion (1.5-2.0 cm) of full-thickness tissue at the head of the inferior turbinate in the region of the internal nasal valve. Limiting partial turbinate resection to this portion of the inferior turbinate allows the surgeon to address the region of greatest nasal airway resistance, while lowering the risk of hemorrhage secondary to injury to the posterior vascular supply.
Further, tissue is sometimes resected from the “scroll” region of the turbinate, inferior to the bone. The tissue to be resected can first be clamped for a short period and injected with anesthetic with epinephrine to decrease the risk of bleeding. The resection can then be performed with a through-cutting instrument or a microdebrider.
Argon plasma coagulation
Argon plasma coagulation allows for contact-free thermocoagulation of tissue by using a current that is conducted through ionized argon gas, which forms an arc of current between the handpiece and the tissue. The energy delivered to the tissue with this technique is limited to 1-2 mm of penetration.
It was first applied in the field of otolaryngology for the treatment of juvenile laryngeal papillomatosis and epistaxis secondary to hereditary hemorrhagic telangiectasias.
When used for the treatment of inferior turbinate hypertrophy, the handpiece applicator is used to pass the argon plasma coagulation beam slowly over the entire length of the lower one-third to one-half of the inferior turbinate in 3-4 parallel lines (Figure 6). Direct contact of the applicator tip with the turbinate tissue is avoided because it prevents the desired effects.
Figure 6Argon plasma coagulation of the inferior turbinate delivers an arc of current to the lower one-third to one-half of the inferior turbinate along the entire length of the turbinate.
Lasers produce a precise beam of coherent light that may be accurately delivered, producing minimal damage beyond the area requiring treatment. Tissue absorption of the energy is dependent on the wavelength of the laser light, which can be delivered in either a pulsed mode or a continuous mode. The use of a laser for inferior turbinate reduction has been around since the late 1970s and is particularly useful when soft tissue hypertrophy predominates.
A number of lasers have been used for this technique, including the argon laser, the carbon dioxide (CO2) laser, the diode laser, the holmium: yttrium aluminum garnet laser, the potassium titanyl phosphate (KTP) laser, and the neodymium: yttrium aluminum garnet (Nd:YAG) laser. Given the considerable differences in the various laser beam properties, such as the degree of hemostasis, tissue ablation, and depth of penetration, the laser systems can be used in a variety of methods to achieve turbinate reduction. This ranges from simple tissue ablation, to laser mucotomy (excision of superficial mucosa), to partial or total turbinectomy with the laser used as a cutting instrument (Figure 1E).
Degloving
Degloving of the inferior turbinate is a technique whereby the soft tissue and epithelium overlying the turbinate bone is resected along the whole length of the turbinate.
Despite results that suggest sustained improvement in nasal obstruction up to 2 years after surgery, this technique is not commonly used owing to fear of tissue overresection, destruction of the important pseudostratified ciliated columnar epithelium, and the possible deleterious effects on normal nasal physiology.
Total resection
Total or “radical” turbinectomy involves the complete resection of the inferior turbinate using heavy scissors to detach it directly at its site of attachment to the lateral nasal wall (Figure 1F). This technique can reduce the nasal resistance up to 50%.
It was commonly used in first half of the twentieth century but eventually fell out of favor with many surgeons owing to concerns for severe long-term complications such as atrophic rhinitis and ozaena.
These complications likely develop secondary to the loss of the inferior turbinate׳s contribution to nasal physiology and are associated with excessive mucosal drying, scarring, foul smelling nasal discharge, and recurrent epistaxis.
The complications of inferior turbinate reduction include postoperative hemorrhage, short- and long-term nasal dryness and crusting, scarring, atrophic rhinitis, ozaena, and “empty nose syndrome.” The reported rates of each of these complications vary from one technique to another.
As previously mentioned, many of these complications may be attributed to aggressive tissue resection and alteration of normal nasal physiology. Many authors have observed that patients who have a total resection of the inferior turbinates can have a paradoxical sensation of nasal congestion, a condition commonly referred to as “empty nose syndrome.” The etiology of this condition is unknown but may be related to the loss or alteration of the normal sensation of breathing through the nose, including the loss of sensory input from the turbinates themselves.
Given the important role the inferior turbinates play in nasal physiology, many contemporary surgeons aim to strike a balance between adequate tissue resection and preservation of as much functional turbinate tissue as possible. This objective has led some researchers to examine the effect that different techniques in inferior turbinate reduction have on mucociliary clearance, as well as the histopathologic features of the turbinate. To date, results have been mixed with a general trend toward better results with radiofrequency and partial resection techniques and worse effects with electrocautery and laser techniques.
Inferior nasal turbinate wound healing after submucosal radiofrequency tissue ablation and monopolar electrocautery: Histologic study in a sheep model.
A consensus based on these results cannot be reached at this time.
Discussion
The optimal surgical technique for inferior turbinate reduction is quite controversial. The existence of the numerous surgical techniques is in itself indicative of the lack of consensus regarding the best method to reduce the inferior turbinates. Fortunately, the body of literature assessing outcomes in inferior turbinate surgery has improved in quality in recent years, and with continued outcomes research, clinical decision making can be guided increasingly by the reported data.
Outfracture
Lateralization of the inferior turbinate is generally considered to have short-lived therapeutic success, owing to the tendency toward remedialization over time. Goode
indicates that not only does the turbinate tend to eventually return to its original position, but the procedure also fails to deal with the primary cause of its enlargement. This notion has been partly challenged by Aksoy et al
whose data demonstrated a sustained reduction in the angle and distance between the inferior turbinate bone and the lateral nasal wall up to 6 months postoperatively. Nevertheless, most surgeons consider this technique to be an adjuvant procedure that works well only in combination with other turbinate reduction techniques, but not alone.
Submucosal electrocautery
Much like the outfracturing technique, the submucosal electrocautery technique is generally considered to have short-lived therapeutic success. Fradis et al
demonstrated an improvement in nasal breathing in 76% of patients treated with submucosal electrocautery 2 months after surgery. However, Jones and Lancer
showed that these results are transitory with no significant difference between the nasal resistances before surgery, and 15 months after surgery. Similarly, Warwick-Brown and Marks
also demonstrated an improvement in nasal breathing and a reduction in turbinate size at 3 months and 1 year after surgery, however, 5-year follow-up data revealed that nasal obstruction and hypertrophy recurred.
Submucosal radiofrequency coblation
On the whole, inferior turbinate reduction by means of radiofrequency coblation has shown encouraging short- and long-term results. Several studies have demonstrated a decrease in nasal obstruction up to 3 months after surgery, including Fischer et al
showed an improvement in nasal obstruction that was sustained up to 6 months in a prospective, blinded, randomized, placebo-controlled study, while additional data reported by Bhattacharyya and Kepnes,
have also demonstrated a significant decrease in nasal obstruction at this time interval. Longer-term follow-up has revealed a sustained improvement. Harsten
reported an improvement in symptoms in 82% of patients on short-term follow-up (4-9 months), and 78% of patients on long-term follow-up (21-30 months). Meanwhile, Cavaliere et al
demonstrated an improvement in turbinate edema and nasal obstruction 20 months after surgery with both monopolar and bipolar radiofrequency coblation, and Porter et al
showed continued benefits with the overall ability to breathe 2 years after surgery in a prospective, single blinded, randomized, placebo-controlled trial. This decrease in nasal obstruction has been demonstrated to last up to 5 years after surgery.
As with radiofrequency coblation, overall encouraging short- and long-term results have been reported with powered submucosal inferior turbinate reduction. In a prospective study, Ozcan et al
also reported sustained improvement in nasal obstruction between 6 and 12 months of follow-up, with 75% of patients reporting no nasal obstruction and 25% of patients reporting only mild nasal obstruction after surgery. Huang and Cheng
Changes in nasal resistance and quality of life after endoscopic microdebrider-assisted inferior turbinoplasty in patients with perennial allergic rhinitis.
Arch Otolaryngol Head Neck Surg.2006; 132: 990-993
found a significant decrease in nasal resistance as well as improvements in quality of life measures, nasal obstruction, rhinorrhea, sneezing, and postnasal drip 1 year after surgery. A much longer 10-year follow-up study by Yanez and Mora
demonstrated that 91% of patients reported no nasal obstruction, with only a 3% recurrence rate of nasal obstruction. Furthermore, endoscopy, anterior rhinomanometry, and mucociliary transit time measurements revealed long-term improvements in this study as well.
Partial resection
Techniques that involve partial resection of the inferior turbinate vary in the amount and location of tissue removal, and consequently, demonstrate varied outcomes that are difficult to compare. Wright et al demonstrated that although trimming of the head of the inferior turbinate resulted in a significant decrease in total nasal resistance to airflow, there was no significant effect on subjective nasal obstruction. Furthermore, up to 20% of patients had a reversal of their initial improvement in nasal obstruction within 2 years of follow-up.
who showed an improvement after anterior turbinectomy in patients followed up for 6 months to 4 years after surgery.
Wexler and Braverman demonstrated good short-term results in a prospective, nonrandomized study of the resection of the medial and inferior portions of the inferior turbinates. The patients in this study had a significant improvement in nasal obstruction and sense of smell, with subepithelial fibrosis and regenerated epithelium at least 4 months after surgery.
used a similar technique and demonstrated a significant improvement in nasal breathing and nasal discharge at 1 week, 3 months, and 1 year after the surgery. Reporting on a longer follow-up period, Passali et al compared 6 different inferior turbinate reduction techniques over a 6-year follow-up period in a prospective randomized trial; a similar technique of partial bone and lateral mucosa resection (with and without lateral displacement of the remaining neoturbinate) produced the best results with significantly improved nasal resistance, nasal volume, and quality of life measures that remained true through the 6-year follow-up period. Furthermore, only this technique achieved normalized mucociliary transport times.
Chevretton et al studied the “degloving” technique whereby the medial and inferior mucosa is removed down to bone in a prospective study. They found a significant improvement in peak inspiratory flow, and an overall improvement in patient satisfaction with nasal symptoms and obstruction up to 2 years after surgery, with no significant change in postnasal drip and saccharin clearance.
reported an improvement in nasal airflow in 67% of patients the first week after surgery and 86% of patients after 3 months. Similarly, Gierek and Jura-Szoltys
reported an improvement in nasal obstruction in 88% of patients 3 months after surgery and 73% of patients after 12 months. In a subsequent prospective study with a mean follow-up period of 12 months, Bergler et al
again reported improved nasal breathing in 76% of patients after 1 week, and 83% after 12 months, while histologic examination demonstrated re-epithelialization in 63% of the patients at 6 weeks and normal cilia after 3 months. Similarly, Ferri et al
reported improved nasal airflow in 87% of patients 2 years after inferior turbinate reduction with argon plasma coagulation.
Laser techniques
Given the numerous laser types (ie, wavelength), parameters (ie, power and energy), and application modalities (ie, contact, noncontact, interstitial, and superficial) that have been used, it is difficult to assess and compare the efficacy of this technique for inferior turbinate reduction on the whole. A review by Janda et al
determined that laser treatment of hyperplastic inferior nasal turbinates achieves comparable results to most conventional techniques in the short term, but seems to be less effective in the long term. However, some authors have published encouraging results.
reported a relief of nasal obstruction in 89% of patients up to 5 years after treatment with the CO2 laser, but a review of the literature reveals a wide range of long-term success rates between 50% and 100% for this technique.
reported on their use of the KTP laser, with 81% of patients reporting good to excellent subjective improvement with 12-20 months of follow-up. Orabi et al
also reported acceptable inferior turbinate reduction with the KTP laser in 83% of patients, although they reported that 28% of patients required medication again to aid in symptom control. Reporting on their experience with the diode laser, Janda et al
reported a significant improvement in nasal airflow and volume, with a subjective improvement in nasal breathing in 86% of the patients at 6 months, and 76% of patients 1 year after laser treatment; other studies have reported similar success.
However, despite the seemingly encouraging results for many of the laser techniques discussed, they are contradicted by studies like that of DeRowe et al
who reported a 1-year improvement of nasal obstruction in 41% (diode laser), 47% (Nd:YAG laser) and 57% (CO2 laser) of patients. The holmium: yttrium aluminum garnet laser has also demonstrated mixed results. Although Leunig et al
reported improved nasal breathing in 77% of patients after 1 year, Serrano reported only a 52% success rate with a mean follow-up of 16 months.
Conclusions
Surgical reduction of the inferior turbinates is an effective treatment modality for patients with chronic nasal obstruction due to inferior turbinate enlargement. Numerous effective techniques exist, but there is a lack of consensus regarding the best one. Most surgeons, however, agree that a balance must be struck between symptom improvement and preservation of normal nasal physiology. Future surgical decision making will undoubtedly be guided by the continuously growing body of quality outcomes research.
References
Scheithauer M.O.
Surgery of the turbinates and “empty nose” syndrome.
GMS Curr Top Otorhinolaryngol Head Neck Surg.2010; 9 ([Doc03])
Improved objective outcomes and quality of life after adenotonsillectomy with inferior turbinate reduction in pediatric obstructive sleep apnea with inferior turbinate hypertrophy.
Radiofrequency treatment of turbinate hypertrophy in subjects using continuous positive airway pressure: A randomized, double-blind, placebo-controlled clinical pilot trial.
Comparison of the effectiveness and safety of radiofrequency turbinoplasty and traditional surgical technique in treatment of inferior turbinate hypertrophy.
Inferior nasal turbinate wound healing after submucosal radiofrequency tissue ablation and monopolar electrocautery: Histologic study in a sheep model.
Changes in nasal resistance and quality of life after endoscopic microdebrider-assisted inferior turbinoplasty in patients with perennial allergic rhinitis.
Arch Otolaryngol Head Neck Surg.2006; 132: 990-993
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