Combined radiofrequency volumetric tissue reduction and lateral outfracture of hypertrophic inferior turbinate in the treatment of chronic rhinitis: short-term and long-term outcome

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

KAAACI Allergic Rhinitis Guidelines: Part 2. Update in Non-pharmacological Management

Allergic rhinitis is the most common chronic disease worldwide. Various upper airway symptoms lower quality of life, and due to the recurrent symptoms, multiple treatments are usually attempted rather than one definitive treatment. There are alternatives to medical (medication-based) and non-medical treatments. A guideline is needed to understand allergic rhinitis and develop an appropriate treatment plan. We have developed guidelines for medical treatment based on previous reports. The current guidelines herein are associated with the "KAAACI Evidence-Based Guidelines for Allergic Rhinitis in Korea, Part 1: Update in pharmacotherapy" in which we aimed to provide evidence-based recommendations for the medical treatment of allergic rhinitis. Part 2 focuses on non-pharmacological management, including allergen-specific immunotherapy, subcutaneous or sublingual immunotherapy, nasal saline irrigation, environmental management strategies, companion animal management, and nasal turbinate surgery. The evidence to support the treatment efficacy, safety, and selection has been systematically reviewed. However, larger controlled studies are needed to elevate the level of evidence to select rational non-medical therapeutic options for patients with allergic rhinitis.

Long-term Outcomes of Turbinate Surgery in Patients With Allergic Rhinitis: A Systematic Review and Meta-analysis

Importance

Turbinate surgery is an effective treatment for allergic rhinitis (AR) refractory to medical treatment. However, the long-term outcomes of turbinate surgery are still unclear and have not yet been confirmed by a meta-analysis and systematic review of the literature.

Objective

To investigate the long-term outcomes and safety of turbinate surgery in AR by performing a meta-analysis.

Data Sources

MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through April 2021.

Study Selection

Studies that analyzed turbinate surgery alone, had a follow-up period of more than 1 year, examined long-term efficacy of turbinate surgery, used current turbinate surgery methods, and were published in a peer-reviewed journal were included. Full-text reviews were performed by 2 independent reviewers. Conflicts were resolved by a third reviewer.

Data Extraction and Synthesis

Descriptive and quantitative data were extracted; weighted mean difference (WMD) was synthesized under a random-effects model. Heterogeneity was assessed using the Q statistic and the I2 metric. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines.

Main Outcomes and Measures

The long-term outcomes of turbinate surgery on subjective nasal symptoms and objective parameters.

Results

Of the 3962 citations retrieved, 18 studies comprising 1411 patients were included. Findings showed significantly decreased symptom scores in nasal obstruction (WMD, 4.60, 95% CI, 3.43-5.76), rhinorrhea (WMD, 3.12; 95% CI, 1.97-4.28), sneezing (WMD, 2.64; 95% CI, 1.74-3.54), itching (WMD, 1.75; 95% CI, 1.20-2.30), and nasal resistance (WMD, 0.16; 95% CI, 0.08-0.24) and a significant increased total nasal volume (WMD, 0.96; 95% CI, 0.73-1.19). There was no significant difference in the occurrence of any complication. More than 1 year after surgery, the improvements in nasal obstruction (WMD, 5.18; 95% CI, 3.00-7.37), rhinorrhea (WMD, 3.57; 95% CI, 1.78-5.37), and sneezing (WMD, 2.95; 95% CI, 1.58-4.32) were maintained.

Conclusions and Relevance

In this systematic review and meta-analysis, turbinate surgery was associated with positive outcomes in AR and maintained the association during long-term follow-up. The rate of complications is also low. These findings can guide the preoperative counseling of patients with AR being considered for turbinate surgery.

Piezo-assisted Turbinoplasty Versus Partial Turbinectomy in External Septorhinoplasty: A Prospective Comparative Study in 100 Patients

OBJECTIVES

The purpose of this study was to compare the outcome of the piezo-assisted turbinoplasty with a partial turbinectomy technique in the treatment of chronic nasal obstruction due to inferior turbinate enlargement.

STUDY DESIGN

This is a prospective randomized single-center study in a cohort of 100 consecutive patients which underwent external septorhinoplasty and concomitant hybrid type of turbinoplasty.

METHODOLOGY

Patients were randomly assigned into two groups. The first group included 50 patients who underwent piezo-assisted outfracturing of the inferior turbinates in combination with bipolar coagulation. The second group included 50 patients who underwent a treatment based on turbinate bipolar coagulation and partial resection of the inferior border of the turbinate. The severity of nasal obstruction was measured in both patient groups with a patient-related outcome questionnaire (NOSE) and objective measures (anterior rhinomanometry and acoustic rhinometry). Assessments were conducted prior to surgery and 3 months after the surgery.

RESULTS

There was a significant improvement in the values of the NOSE questionnaire with no relevant difference between the two study groups. Acoustic rhinometry and rhinomanometry also showed no statistically significant differences between the two study groups. No differences in postoperative healing were found, and postoperative complications were comparable low in both groups. However, the piezo-assisted procedure was quicker to perform with only minimal bleeding.

CONCLUSION

During septorhinoplasty, the combination of thermo-coagulation with piezo-assisted turbinoplasty was as efficient as with partial turbinectomy to establish normal nasal breathing.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does inferior turbinate outfracture provide additional benefit when combined with inferior turbinate radiofrequency ablation?

PURPOSE

To evaluate, both subjectively and objectively, whether turbinate outfracture provides any additional benefit in the treatment of inferior turbinate hypertrophy when combined with radiofrequency ablation.

METHODS

The study was conducted on 58 patients diagnosed with inferior turbinate hypertrophy. The patients were randomly divided into two groups according to the treatment they receive. Group A consisted of patients undergoing radiofrequency ablation and Group B included patients undergoing turbinate outfracture in combination with radiofrequency ablation. For the purposes of objective evaluation, all patients underwent acoustic rhinometry and anterior rhinomanometry preoperatively and at 6 months postoperatively. In addition, for subjective evaluation, the patients completed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. Postoperative changes in objective and subjective parameters in both groups versus the preoperative period and their differences were compared statistically.

RESULTS

In Group A, mean postoperative minimal cross-sectional area (MCA) and nasal volume (NV) values and NOSE scores were significantly greater compared to those obtained in the preoperative period. Similarly, Group B showed significantly greater mean postoperative MCA, NV and NOSE score values compared to the preoperative period. In Group A and B, mean postoperative total nasal resistance (TNR) value was significantly lower in comparison to the preoperative period. The differences in mean preoperative and postoperative MCA, NV, TNR and NOSE scores were significantly greater in Group B versus Group A.

CONCLUSION

The addition of turbinate outfracture to inferior turbinate radiofrequency ablation treatment provides both objective and subjective benefits in the resolution of nasal obstruction.

Surgical Management of Nonallergic Rhinitis

Nonallergic rhinitis (NAR) describes chronic symptoms of nasal congestion, obstruction, and rhinorrhea unrelated to a specific allergen based on skin or serum testing. Vasomotor rhinitis is the most frequent subtype of NAR. Although medical management is the first-line treatment of NAR, there is a role for surgical therapy when medications fail to improve symptoms. Surgical options for NAR include inferior turbinate reduction and botulinum toxin injection as well as more directed targeting of the autonomic nerve supply to the nasal cavity through vidian neurectomy, posterior nasal neurectomy, and cryoablation of the posterior nerve.

Comparison of Emla cream and lidocaine injection for local anaesthetic before radiofrequency reduction of the inferior turbinates

We compared the effectiveness of local anaesthetic with Emla cream with that of an injection of lidocaine for radiofrequency reduction of the inferior turbinates. We studied 98 consecutive patients with hypertrophied inferior turbinates, 46 of whom were given Emla cream and 52 lidocaine injection. The procedure began five minutes after the injection of lidocaine and 10minutes after the Emla cream had been applied. Patients were asked to indicate on a visual analogue scale (VAS) the degree of perioperative pain, anxiety, sensation of choking, and discomfort on swallowing that they felt after the procedure. Patients treated with Emla had significantly lower VAS scores for discomfort on swallowing than those treated with lidocaine (p=0.001), but there were no other significant differences between the two groups. We conclude that Emla cream is an efficacious alternative to infiltration of lidocaine for radiofrequency reduction of the inferior turbinates.

Update on surgical management of adult inferior turbinate hypertrophy

PURPOSE OF REVIEW

There are numerous surgical managements of hypertrophic inferior turbinate. Controversy still exists involving the optimal surgical technique for hypertrophic inferior turbinate. The current review will discuss the most commonly used techniques for turbinate surgery and highlight their recently published clinical outcomes.

RECENT FINDINGS

Microdebrider-assisted turbinoplasty, along with total removal of inferior turbinate mucosa, turned out to have no negative impact on healing time and no adverse postoperative events. The majority of recently published studies were focused on surgical outcomes of radiofrequency ablation. It appears that radiofrequency ablation could improve nasal resistance, sense of smell, and nasal mucociliary function. A 1470-nm diode laser was found superior to a conventional 940-nm diode laser in reducing scar formation. Ultrasonic bone aspirator was used to manage hypertrophic inferior turbinate caused by bone enlargement. Few recent literatures report turbinectomy.

SUMMARY

Inferior turbinate surgery offers benefit and improves nasal obstruction in patients with hypertrophic inferior turbinate refractory to medical treatment. Rigorously designed study including subjective and objective measurements, control or comparison group, and long-term follow-up should be carried out in the future.

A randomized study of temperature-controlled versus bipolar radiofrequency for inferior turbinate reduction

The objective of this study is to compare outcomes of temperature-controlled radiofrequency (TCRF) and bipolar radiofrequency (BRF) for inferior turbinate reduction in patients with chronic rhinitis (CR). This was a prospective, randomized non-inferiority trial. Eighty-four adult patients with CR refractory to medication were randomized into two intervention groups: TCRF(42) or BRF(42). Primary outcomes consisted of patient-orientated visual analog scale (VAS; 0-10) of nasal obstruction at 4th postoperative week. Secondary subjective outcomes included VAS of nasal discharge, sneezing, hyposmia, and postnasal drip. Objective outcomes included crusting, mucociliary transportation time, minimal cross-sectional area, total nasal volume, and nasal airway resistance performed by blind assessors before and at 4th postoperative week and 1-year follow-up. Baseline and perioperative data showed no statistically significant difference between both groups, except for longer operative time in TCRF (481.5 ± 36.2 vs. 37.1 ± 3.0 s, p < 0.001) and slightly more crusts in BRF group (p = 0.04). Both intention-to-treat and per-protocol analyses, TCRF(39) versus BRF(41), revealed no significant difference among subjective and objective outcomes between two groups at 4th postoperative week. The 95% confidence intervals of mean differences of VAS scores of all subjective symptoms were within defined margin (-1.5 to 1.5), except for nasal discharge. At 1-year follow-up, there was still no significant difference in the outcomes. Minimal pain and minor bleeding without serious adverse effects from both interventions were reported. Both BRF and TCRF resulted in similar short-term outcomes, while less operative time was found in BRF group. Further studies, particularly, on cost-effectiveness should be conducted for better treatment selection.

LEVEL OF EVIDENCE

1b.