Submucous diathermy of the inferior turbinates in chronic hypertrophic rhinitis

The Effectiveness of High-Intensity Focused Ultrasound in Treating Nasal Obstruction Caused by Inferior Turbinate Hypertrophy: A Clinical Study

Background Nasal obstruction due to inferior turbinate hypertrophy is a common medical complaint among ENT clinic patients, which can significantly affect the patient's quality of life, and some are compelled to use topical intranasal decongestants. Conservative management is the first line of treatment; however, surgical reduction of the inferior turbinate becomes necessary if the symptoms persist after three months of treatment. The optimal surgical technique is controversial. High-intensity focused ultrasound (HIFU) is a minimally invasive surgical option that targets tissue volume precisely and minimally impacts surrounding tissue. This study aimed to assess the effectiveness and safety of HIFU in treating patients suffering from nasal obstruction due to inferior turbinate hypertrophy. Methods This prospective study was conducted from February to December 2016. The study lasted over six months. Patients with a history of allergic and non-allergic rhinitis participated in this study. It included 43 patients who had been experiencing chronic nasal obstruction due to bilateral inferior turbinate hypertrophy and had not shown improvement after three months of medical treatment. The patients underwent Ultrasound Volumetric Tissue Reduction (UVTR) surgery using the D & A Ultrasurg device (Diamant Medical Equipment Ltd., Amman, Jordan) under local anesthesia. The effectiveness, safety, and tolerance of HIFU were assessed subjectively for six months using a well-designed questionnaire utilizing a visual analog scale (VAS) and nasal endoscopy after the surgery. Results The study included 43 patients, 22 male and 21 female, aged 13 to 65 years. The study found that 40 (93%) patients showed significant improvement in nasal obstruction within a month of the surgery. However, three (7%) patients continued to experience persistent nasal obstruction even after six months of follow-up. The procedure was well-tolerated, with low rates of complications after surgery and reasonable pain control. During the surgery, 20 (46.5%) patients reported mild pain described as a pressure-like sensation, and 10 out of 43 patients (23%) required paracetamol after the procedure. Four patients (9.3%) had mild bleeding, which was treated with an ultrasound nasal probe without nasal packing. All patients experienced crusting of the nasal cavity during the first week, but no crustation was observed after the first month. There were no reported cases of synechia among the patients. Conclusion This study confirms that HIFU treatment is a reliable and effective treatment for improving short-term nasal obstruction caused by inferior turbinate hypertrophy. The procedure is easily applied and well-tolerated in outpatient clinics.

Treating Chronic Rhinitis and Turbinate Hypertrophy Without Surgery: The Effectiveness of Silver Nitrate Cauterization

INTRODUCTION

Chronic rhinitis and chronic turbinate hypertrophy are conditions that affect the quality of life of individuals. The conchas, or the three half-crescent-shaped structures in the nasal cavity, play a crucial role in the respiratory system by filtering and humidifying the air we breathe. The growth of the conchas outside of normal physiological conditions can lead to conditions such as hyperplasia of the inferior turbinate and hypertrophy of the inferior turbinate.

METHODS

The study was conducted between June 2020 and December 2022 and aimed to evaluate the effect of silver nitrate cauterization on patients with chronic rhinitis and chronic turbinate hypertrophy. A total of 638 patients and 520 controls with nasal obstruction were included in the study and underwent silver nitrate cauterization without the need for surgical intervention. The treatment was performed under local anesthesia and involved the application of silver nitrate on the anterior one-centimeter part of the medial surface of both inferior turbinates. Patients were instructed to use an isotonic solution nasal spray and take an antihistamine pill for seven days.

RESULTS

A significant improvement was observed in the overall inspiratory function without the need for nasal decongestant sprays or surgery in all patients after one and three months. There was also a significant improvement noted three months after the silver nitrate cauterization in the Nasal Obstruction Symptom Evaluation (NOSE) scores, which measure the level of nasal obstruction.

CONCLUSION

Silver nitrate cauterization showed to be an effective treatment for patients with turbinate hypertrophy, leading to an improvement in overall inspiratory function and reducing the severity of nasal obstruction. This treatment can serve as an alternative to surgical intervention for these conditions.

Inferior Turbinate Reduction: Diode LASER or Conventional Partial Turbinectomy?

Hypertrophy of inferior nasal turbinate is one of the most common causes for nasal obstruction (NO). As diode laser has proven to be as effective as any other lasers, our objective was to study various primary outcomes of its use of diode laser like improvement in NO, intraoperative bleeding, postoperative pain, and rapidity of healing. The study was undertaken to compare the various outcomes by diode laser turbinate reduction (LTR) and conventional partial inferior turbinectomy (PIT). A nonrandomized controlled trial was conducted on 2 groups: One group (30 cases) underwent LTR and PIT was performed in the other group (30 cases). The improvement in NO was measured postoperatively up to 6 months. Intraoperative bleeding was measured and postoperative pain scores were assessed each day up to fifth postoperative day. Lastly, rapidity of healing was evaluated until 6 months. Subjective relief of NO was 90.8% in LTR group, whereas it was 65% in PIT group at 6-month follow-up, which was statistically significant (P < .05). Pain scores were higher until 5 days in PIT group compared to LTR group (P = .0001). Intraoperative bleeding mean scores (milliliters) were 8.03 in LTR group compared to 23.29 in PIT group (P = .00001). Rapidity of healing was faster in LTR group with mean scores of 3.03 weeks in comparison to PIT group where it was 6.33 weeks (P = .00001). Compared to the conventional technique, the outcomes were better with diode laser and caused less morbidity.

Patulous nasolacrimal duct with air reflux: a complication of submucosal diathermy of the inferior turbinate

BACKGROUND

Submucosal diathermy to the inferior turbinate is a widely practised procedure to improve the nasal airway when nasal obstruction is due to hypertrophy of the inferior turbinate. This paper reports a case of an unusual nasolacrimal complication following submucosal diathermy to the inferior turbinate, and reviews the relevant literature.Case reportA 33-year-old male patient developed a patulous nasolacrimal duct opening following submucosal diathermy of the inferior turbinate. This resulted in spontaneous reflux of air and nasal mucus on to the ocular surface.

CONCLUSION

This newly recognised complication of submucosal diathermy to the inferior turbinate indicates the need to be aware of the potential risk to the nasolacrimal system with this technique.

The effect of inferior turbinate surgery on ciliated epithelium: A randomized, blinded study

OBJECTIVES/HYPOTHESIS

The aim of this study was to evaluate statistically the effects of radiofrequency ablation, diode laser, and microdebrider-assisted inferior turbinoplasty techniques on ciliated epithelium and mucociliary function.

STUDY DESIGN

Prospective randomized study.

METHODS

A total of 66 consecutively randomized adult patients with enlarged inferior turbinates underwent either a radiofrequency ablation, diode laser, or microdebrider-assisted inferior turbinoplasty procedure. Assessments were conducted prior to surgery and 3 months subsequent to the surgery. The effect on ciliated epithelium was evaluated using a score based on the blinded grading of the preoperative and postoperative scanning electron microscopy images of mucosal samples. The effect on mucociliary function, in turn, was evaluated using saccharin transit time measurement.

RESULTS

The score of the number of cilia increased statistically significantly in the radiofrequency ablation (P = .03) and microdebrider-assisted inferior turbinoplasty (P = .04) groups, but not in the diode laser group. The score of the squamous metaplasia increased statistically significantly in the diode laser group (P = .002), but not in the other two groups. There were no significant changes found between the preoperative and postoperative saccharin transit time values in any of the treatment groups.

CONCLUSIONS

Radiofrequency ablation and microdebrider-assisted inferior turbinoplasty are more mucosal preserving techniques than the diode laser, which was found to increase the amount of squamous metaplasia at the 3-month follow-up. The number of cilia seemed to even increase after radiofrequency ablation and microdebrider-assisted inferior turbinoplasty procedures, but not after diode laser. Nevertheless, the mucociliary transport was equally preserved in all three groups.

LEVEL OF EVIDENCE

1b Laryngoscope, 129:18-24, 2019.

Nasal Function following Carbon Dioxide Laser Turbinate Surgery for Allergy

A carbon dioxide laser (CO2 laser) was used to treat the hypertrophic inferior turbinates of 121 patients with nasal symptoms related to house dust allergy. Follow-up ranged from 6 to 48 months (mean follow-up period: 17.8 months). Treatment involved 10–14 watts of a defocused pulse beam of a CO2 laser fitted with special handpieces. Subjectively, 111 of the 121 patients (91.7%) reported a reduction in nasal stuffiness, 76 of the 112 patients (67.9%) had reduction in rhinorrhea, and 63 of the 96 patients (65.7%) had decrease in sneezing. Nasal airflow resistances were confirmed to have decreased in 82 patients using rhinomanometry. Nasal provocation reactions by a house dust disk, which were investigated in 10 patients, showed a tendency to reduce from 1 to 11 months after laser treatment. Nasal mucociliary transports, which were followed by the saccharin test in 50 patients, recovered 1–1.5 months after the laser surgery. To study mucosal structure after laser irradiation, the inferior turbinates of five patients were examined under a light microscope. The ciliated epithelium was shown to have recovered on light microscopic examination, whereas the number of goblet cells decreased. A net of new collagen fibers was observed in the superficial submucosa a few months after treatment. The quantity of submucosal glands was reduced in the treated portion. Such findings suggested that CO2 laser turbinate surgery may be effective in relieving the nasal symptoms associated with allergy.

Endoscopic Submucosal Resection Versus Endoscopic Submucosal Diathermy for Inferior Turbinate Hypertrophy

Endoscopic submucous resection and endoscopic submucous diathermy of the inferior turbinate are two different surgical methods of reducing size in turbinate hypertrophy. We aimed to compare the efficacy of both methods in reducing the nasal symptoms and improving nasal airway. This is a prospective randomized controlled trial conducted in a tertiary hospital, involving fifty patients with inferior turbinate hypertrophy not relieved by medications. After preoperative airway grading using a subjective symptom score, objective airway score and endoscopic score, patients were randomized to undergo either endoscopic submucous diathermy or endoscopic submucous resection. The primary outcome was postoperative improvement of airway and reduction of nasal symptoms. Secondary outcomes were postoperative bleeding and pain. All 24 patients who underwent endoscopic submucous diathermy and 26 who underwent endoscopic submucous resection showed statistically significant reduction in nasal symptoms both in the immediate and late postoperative periods. Patients who underwent endoscopic submucous resection showed greater improvement of airway at 1 week than those who had endoscopic submucous diathermy (p = 0.001). This difference however equalized at the 3-6 months postoperative period. Postoperative bleeding (p = 0.02) and pain (p = 0.04) were significantly more in patients who underwent endoscopic submucous resection. Both endoscopic submucous diathermy and endoscopic submucous resection are equally effective in improving airway in inferior turbinate hypertrophy with a slight advantage of endoscopic submucous resection in the early postoperative period. Reduced postoperative bleeding and pain may make endoscopic submucous diathermy a more attractive option overall.

Effects of surgical treatment of hypertrophic turbinates on the nasal obstruction and the quality of life

PURPOSE

Chronic hyperplasia of the inferior nasal concha is accompanied by a nasal obstruction; however, there is no standardised surgical treatment for this condition. Here, we compared the outcome of three surgical techniques frequently used to treat the hyperplasia of inferior turbinates: turbinectomy with lateralization, submucosal electrocautery and laser cautery additional to septoplasty.

MATERIALS AND METHODS

One hundred and nine patients participated in this prospective randomized study upon signing written consent. The subjects were randomly assigned to one of three intervention groups: 1) submucosal turbinectomy with lateralization, 2) submucosal electrocautery or 3) laser cautery. All groups were followed-up for up to 6months after surgical intervention. During the four follow-up appointments, the outcomes were measured with the modified German version of Sino-Nasal Outcome Test 20 questionnaire. In addition, the nasal breathing and the absolute nasal flow rates and respective mucosal component were determined by the anterior rhinomanometry.

RESULTS

Following surgery, the subjective and objective nasal obstruction decreased significantly in all three groups. Moreover, the subjective symptoms measured by modified Sino-Nasal Outcome Test 20 improved significantly, although there were some temporal differences between groups regarding subjective nasal obstruction, ear pressure, nasal discomfort, daytime fatigue, cough and dry mouth. The mucosal component of nasal congestion decreased significantly after surgery.

CONCLUSIONS

All surgical techniques used to reduce the conchae mucosa led to a significant improvement in the objective and subjective nasal breathing and the quality of life. Septoplastic reduction proved to be of additional benefit.

A comparative study of radiofrequency assisted versus microdebrider assisted turbinoplasty in cases of inferior turbinate hypertrophy

Nasal obstruction is the most common complaint among patients presenting to otolaryngologists which disturbs the quality of life of the patient. The anterior end of inferior turbinate is in the narrowest part of nasal airway, enlargement of which causes significant nasal obstruction. In our, prospective and interventional, study a comparison was made between the results of bipolar radiofrequency assisted turbinoplasty and microdebrider assisted turbinoplasty in patients with chronic nasal obstruction due to inferior turbinate hypertrophy, not responding to medical treatments. The cases were randomly divided into radiofrequency (RF) and microdebrider (MD) groups, each consisting of 30 cases. Nasal obstruction, sneezing, itching in nose, rhinorrhea, intra operative bleeding, duration of surgery, post operative bleeding, post operative pain and crusting were the parameters recorded preoperative, intra operative and post operatively at 1 week, 1, 3 and 6 months. For bleeding and crusting standard 4-point scale was used. Rest of the symptoms were assessed subjectively on standard visual analogue scale (0-10). The statistical analysis was done by student's t test. Postoperatively, all the preoperative symptoms were significantly improved up to 6 months in group RF as well as group MD, but there were three cases of recurrence at 6th months of postoperative period in group RF. However, we recommend MD assisted inferior turbinoplasty under local anaesthesia in view of long term symptom relief and lesser recurrence.

Comparison between power-assisted turbinoplasty and submucosal resection in the treatment of inferior turbinate hypertrophy

OBJECTIVES

To compare the efficacy of power-microdebrider-assisted inferior turbinoplasty (PAT) with submucosal resection (SMR) in the treatment of inferior turbinate hypertrophy.

METHODS

A prospective randomized clinical trial study of 46 patients with bilateral inferior turbinate hypertrophy. Patients were randomly divided into 2 groups: PAT and SMR.

RESULTS

Intraoperative blood loss was 37.1 ± 7.4 ml in the PAT group and 47.8 ± 9.5 ml in the SMR group (means ± SD), while the operative times were 11.1 ± 1.7 and 29.4 ± 4.7 min, respectively. There was statistically significant lower blood loss in the PAT group, due to the shorter operating time.

CONCLUSION

PAT is equally as safe and effective as SMR. It has a shorter operation time and reduced intraoperative blood loss.

Cytology of nasal mucosa, olfactometry and rhinomanometry in patients after CO2 laser mucotomy in inferior turbinate hypertrophy

To evaluate the cytology of nasal mucosa and sense of smell and nasal patency in patients underwent carbon dioxide laser turbinoplasty (CO2 laser mucotomy) due to chronic nasal hypertrophy. 46 patients with inferior turbinate hypertrophy underwent complete laryngological examination, anterior rhinomanometry, olfactory measurements and cytology of nasal mucous which were performed before and 3 months after CO2 laser mucotomy. Laser mucotomy was performed under local anesthesia. Cytograms revealed significant changes in cell proportion before and after the surgery. Goblet cells predominated in nasal smears before the laser mucotomy. An average percentage of eosinophils in evaluated cytograms before the surgery was 2.1%. Three months after laser mucotomy we observed decrease in goblet cells proportion (the mean range of goblet cells was 16.4%) in nasal cytology. We have also observed improvement in olfactory function, however only in 7 patients (20.6%). The mean value of total nasal airway resistance (NAR) before treatment was 0.98+/-0.24 Pa/cm3/s at 75 Pa. Rhinomanometry after 3 months showed a reduction in mean total resistance from the pretreatment level to 0.77 Pa/cm3/s. We believe that CO2 laser mucotomy is an efficacious, minimally invasive and easy to use treatment of inferior turbinate hypertrophy which is performed under local anesthesia with little discomfort for the patient and does not require hospitalization.

Comparison of ultrasound turbinate reduction, radiofrequency tissue ablation and submucosal cauterization in inferior turbinate hypertrophy

Chronic nasal obstruction owed to chronic hypertrophic rhinitis is a common cause of nasal airway obstruction. In cases unresponsive to conservative treatment, various surgical techniques are commonly performed, but the issue of the optimal surgical procedure is still controversial. The objective of the present study was to evaluate the effectiveness and safety of ultrasound treatment of the hypertrophied inferior turbinates, which is a technique recently applied in rhinologic surgery. We aimed, also, to compare this method with the radiofrequency cold coblation turbinate reduction and the traditional submucosal monopolar inferior turbinate cauterization. We studied prospectively 60 patients with chronic hypertrophic rhinitis of nonallergic etiology, who underwent different surgical methods of turbinate reduction, divided into two groups: (1) in 30 patients, inferior turbinate volume reduction using ultrasound procedure on the left side and monopolar diathermy on the right was performed; (2) in 30 patients, radiofrequency coblation technique on the left side and ultrasound turbinate reduction on the right side was undertaken. Subjective evaluation of nasal obstruction and pain was performed using visual analog scales and objective evaluation of the surgical outcome was obtained using active anterior rhinomanometry and acoustic rhinometry. Examinations were performed preoperatively, and 1, 3 and 6 months after surgery. Both subjective and objective evaluation showed significant postoperative improvement in all cases. The best results were obtained with the ultrasound procedure, and second with the radiofrequency technique. The least improvement was observed in the electrocautery group, although its results did not differ significantly from the radiofrequency group. It may be, thus, concluded that ultrasound turbinate reduction is an effective and safe procedure for the management of chronic hypertrophic rhinitis, in patients failing to respond to medical treatment. Using this method, better results were obtained in decreasing subjective symptoms and nasal obstruction, in comparison with radiofrequency and electrocautery.

Surgical management of adult inferior turbinate hypertrophy: a systematic review of the evidence

OBJECTIVES/HYPOTHESIS

The evidence-based medicine (EBM) schema advocates critical appraisal of the scientific literature for treatment of diseases. The objective of this review was to analyze the role of surgery for symptomatic adult inferior turbinate hypertrophy (ITH) by focusing on the following question: In adults with nasal airway obstruction (NAO) from documented ITH having failed medical therapy, does inferior turbinate surgery improve disease-specific quality of life, symptoms, and/or objective parameters with minimum 6-month follow-up?.

STUDY DESIGN

Evidence-based review.

METHODS

Articles for inclusion were identified by query of appropriate search terms in the PubMed database. The articles were reviewed independently by two authors and assigned an evidence level based on standard EBM guidelines.

RESULTS

The search yielded 514 abstracts for review, retrieved 143 abstracts for full review, and included 96 articles in the report. The majority of the articles were assigned level 4 (75) or level 5 (18) evidence. One report was assigned level 1 and two reports were assigned level 2. Median number of patients reported was 50 (range, 1-533). Subjective assessment parameters were reported in 80 studies. Objective parameters were evaluated in 36 studies, including acoustic rhinometry or rhinomanometry (26) and mucociliary function (8). Overwhelming data supported efficacy of surgery for NAO from ITH with positive results reported in 93 studies.

CONCLUSIONS

The literature provides considerable level 4 and 5 evidence for efficacy of surgery for adult symptomatic ITH. Given the paucity of level 1 and 2 data, future studies should focus on prospective studies with matched control groups for comparison.

[Clinical effect of bipolar radiofrequency thermotherapy on allergic rhinitis]

The clinical effect of bipolar radiofrequency thermotherapy on allergic rhinitis was evaluated. A bipolar radiofrequency system (CelonLab ENT) was used on 16 patients suffering from allergic rhinitis from February 2003 and August 2003. The thermotherapy was conducted under local anesthesia and data was collected by preoperative questionnaire and rhinomanometry and 2 months and 2 years postoperatively. Nearly all the patients reported relieved nasal patency, rhinorrhea, and sneezeing. Statistically significant improvements were observed for all the measured VAS scores: nasal patency, rhinorrhea, and sneezeing. Nasal resistance measured by anterior rhinomanometry also significantly improved. We concluded that CelonLab ENT is effective and safe in treating allergic rhinitis.

Mucosal changes in chronic hypertrophic rhinitis after surgical turbinate reduction

Chronic nasal obstruction owed to chronic hypertrophic rhinitis is one of the most common problems encountered in rhinology. Various forms of conservative therapy have been used, but these are often ineffective and surgical reduction techniques have been successfully applied. However, the issue of postoperative histological changes in the nasal mucosa has not been adequately addressed. The aim of the present study was to comparatively evaluate the effect of the methods of submucosal monopolar diathermy, radiofrequency coblation and ultrasounds on the nasal mucosa. Sixty patients with chronic hypertrophic rhinitis of nonallergic etiology underwent different surgical methods of turbinate reduction, divided into two groups: (1) 30 patients underwent tissue volume reduction of the inferior nasal turbinates using ultrasound procedure on the left side and monopolar diathermy on the right; (2) 30 patients underwent radiofrequency coblation technique on the left side and ultrasound reduction on the right. We studied 20 preoperative specimens of the inferior turbinate mucosa taken randomly from both groups of patients, 5 from each side of each group. Normal nasal mucosal specimens taken from ten healthy persons were used as controls. Specimens of the inferior turbinate were taken after 1, 3, and 6 months after surgery, from the same patients. All specimens were examined by electron microscopy. Preoperative observation revealed degeneration of epithelial cells, loss of cilia, disruption of intercellular connections, edema, nasal mucus overproduction and inflammatory infiltration in chorium. Postoperative observations revealed decrease of intercellular edema, reduction of mucus, overproduction of collagen and degeneration of the epithelium to flattened stratified. Only specimens after use of ultrasounds showed islands with normally organized epithelium of columnar ciliated cells. It may be concluded that epithelial changes owed to chronic hypertrophic rhinitis do not significantly improve postoperatively after turbinate tissue volume reduction. Only in several cases operated with ultrasounds, regeneration of epithelium occurs, resulting to anatomical and functional restoration of the nasal physiology.

Efficacy of inferior turbinate coblation for treatment of nasal obstruction

OBJECTIVE

To determine the efficacy of inferior turbinate coblation for the treatment of nasal obstruction.

METHODS

Twenty patients awaiting submucosal diathermy to the inferior turbinates were recruited into the study. All underwent inferior turbinate coblation. Pre-operative and post-operative nasal function was investigated using posterior rhinomanometry and subjective symptom scales.

RESULTS

There was no significant increase in nasal conductance two weeks after inferior turbinate coblation (p = 0.159). However, three months after inferior turbinate coblation, median nasal conductance had increased significantly, from 203 to 324 cm3/s (p = 0.004). The median increase in nasal conductance was 73 cm3/s or 43.5 per cent. Post-operative visual analogue patients' reported post-operative visual analogue scales scores for nasal obstruction decreased significantly, both two weeks (p = 0.006) and three months after inferior turbinate coblation (p = 0.001) when compared to Pre-operative values. There was no change in the reported severity of rhinorrhoea, nasal itching or sneezing. There was a significant relationship (rho = -0.57, p = 0.014) between pre-operative nasal conductance and change in nasal conductance after inferior turbinate coblation.

CONCLUSIONS

This study confirms the short-term efficacy of inferior turbinate coblation for the treatment of nasal obstruction. The benefit was greatest in patients with lower pre-operative nasal conductance. Objective measures of nasal obstruction may be important when selecting patients for inferior turbinate coblation.

Patients with positive allergen test have less favorable outcome after endoscopic microdebrider-assisted inferior turbinoplasty

BACKGROUND

Endoscopic microdebrider-assisted inferior turbinoplasty is a newly developed surgical technique to treat patients with nasal obstruction. Although the procedure has been reported to be safe and effective, we tested the hypothesis that the prognosis might deteriorate with time in allergic rhinitis patients as identified by a positive allergen test in patients who have a persistent regional inflammation of the nose. We assessed the degree of nasal obstruction in a prospective cohort to investigate whether positive allergen test predicts outcome.

METHODS

In 70 consecutive patients, the symptom of nasal obstruction was evaluated subjectively by a visual analog scale (VAS) and objectively by acoustic rhinometry using cross-sectional area of the second notch (CSA-2) and nasal cavity volume before operation, and 3 months, 12 months after operation, respectively. Then, patients were classified and compared according to the multiple-antigen simultaneous test (MAST).

RESULTS

Both MAST(+) and MAST(-) groups showed statistically significant improvement in VAS score, CSA-2, and nasal cavity volume at 12 months after operation (p < 0.01). Of note, MAST(+) patients showed less favorable results than MAST(-) patients at 12 months after operation (p < 0.05).

CONCLUSION

Microdebrider-assisted inferior turbinoplasty provides effective relief for patients with nasal obstruction. However, such turbinate surgery may be successful only for a short period of time in patients with allergic rhinitis. Our finding suggests that, in selecting appropriate candidates, surgeons should consider criteria other than symptomatology, especially in patients with allergic rhinitis who may have manifestations other than at the level of the inferior turbinate contributing to nasal blockage.

Patient satisfaction survey of outpatient-based topical local anesthetic KTP laser inferior turbinectomy: a prospective study

BACKGROUND

The aim of this study was to determine patient satisfaction and feasibility of performing KTP laser inferior turbinectomy under topical anesthetic/decongestant spray. A prospective survey study was performed in the Outpatients' Department of a District General Hospital.

METHODS

Thirty-nine consecutive patients suffering from allergic or nonallergic vasomotor rhinitis were prospectively entered into the study. Preoperative details were gathered including current nasal obstruction score as indicated on a visual analog score (VAS). Lidocaine hydrochloride 5% w/v and phenylephrine hydrochloride 0.5% w/v was applied via topical spray to anesthetize and decongest the nose. The inferior turbinates (ITs) were reduced by parallel mucosal cuts using the KTP laser. Intraoperative details were recorded included pain experienced and bleeding. We studied the subjective clinical effectiveness and patient satisfaction.

RESULTS

All patients were followed up at standard intervals by telephone over a 6-month period. At each interval, current nasal obstruction, pain, bleeding, and crusting on VAS were collected. Morbidity was determined in terms of return to work, return to hospital, or recurrence of symptoms. At the end of 6 months all patients were asked if they would have the procedure repeated again and/or recommend it to a friend. Reduction of ITs under topical anesthesia was acceptable to 83% of all patients. Eighty-seven percent of all patients felt they would recommend the procedure and mode of anesthesia to a friend. Our patients obtained the maximum subjective benefit at 6 weeks postoperatively. A significant improvement in nasal obstruction was achieved. There was subjective improvement in associated symptoms including hyposmia/anosmia, rhinorrhea, and sneezing. Only 28% of all patients required medication again to aid symptom control. Postoperative bleeding was insignificant. The return to a ward or clinic was minimal and 82% of all employed patients were back at work within a week.

CONCLUSION

Our study showed that KTP laser inferior turbinectomy is suitable to be performed in the outpatient department under topical anesthetic/decongestant spray and provides excellent relief for nasal obstruction and high patient compliance and satisfaction.

Comparison of microdebrider-assisted inferior turbinoplasty and submucosal resection for children with hypertrophic inferior turbinates

OBJECTIVES

The aim of this study was to compare the effectiveness and safety of microdebrider-assisted inferior turbinoplasty (MAIT) with submucosal resection (SR) for children with hypertrophic inferior turbinates.

MATERIALS AND METHODS

One hundred and twenty children with chronic nasal obstruction due to hypertrophic inferior turbinates were enrolled. These children were randomly assigned to receive SR of the inferior turbinate (n=60) or MAIT (n=60). Ten children who did not appear to display any nasal discomfort served as normal controls. Surgical-outcome was evaluated with respect to four distinct parameters: nasal endoscopy, subjective assessment of nasal symptoms by the patient using a visual analogue scale, anterior rhinomanometry, and saccharin test. These evaluations were conducted before surgery and at 1 week, 1 and 3 months after surgery.

RESULTS

In the SR group, turbinate edema was decreased significantly at 1 and 3 months after surgery (p<0.05). Nasal secretions and crusting were increased significantly (p<0.05) in the SR group at 1 week after surgery and then decreased significantly at 1 and 3 months after surgery. In the MAIT group, turbinate edema and nasal secretions were decreased significantly at 1 and 3 months after surgery (p<0.05). Nasal crusting was not observed after surgery. Subjective complaints including nasal obstruction, sneezing, rhinorrhea and hyposmia were significantly improved in both groups from 1 month after surgery (p<0.05). Rhinomanometric assessment did not reveal significant improvement until 3 months after surgery in both groups. Saccharin transit time was significantly increased (p<0.05) compared to baseline at 1 week after surgery in the SR group but was not significantly different in the MAIT group.

CONCLUSION

MAIT and SR are both effective at relieving nasal obstruction due to the presence of hypertrophic inferior turbinates. MAIT is superior to SR with regard to preserving the nasal mucosa.

Treatment of inferior turbinate hypertrophy: a randomized clinical trial

In the past 130 years, many surgical procedures for turbinate reduction have been developed. We analyzed the long-term efficacy of 6 of these surgical techniques (turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateral displacement) over a 6-year follow-up period. We randomly divided 382 patients into 6 therapeutic groups and surgically treated them at the Department of Otorhinolaryngology of the University of Siena. After 6 years, only submucosal resection resulted in optimal long-term normalization of nasal patency and in restoration of mucociliary clearance and local secretory IgA production to a physiological level with few postoperative complications (p < .001). The addition of lateral displacement of the inferior turbinate improved the long-term results. We recommend, in spite of the greater surgical skill required, submucosal resection combined with lateral displacement as the first-choice technique for the treatment of nasal obstruction due to hypertrophy of the inferior turbinates.

Bipolar radiofrequency-induced thermotherapy of turbinate hypertrophy: pilot study and 20 months' follow-up

OBJECTIVES/HYPOTHESIS

The present report is a pilot clinical study about a new bipolar ablation technique for the treatment of turbinate hypertrophy, which offers an alternative to conventional methods.

STUDY DESIGN

Prospective, clinical.

METHODS

From August 1999 to March 2000, a new bipolar radiofrequency system with acoustic feedback control was submucosally applied for the treatment of 38 patients with nasal airway obstruction of vasomotor (n = 31) or allergic (n = 7) genesis. The therapy was made ambulatory with surface anesthesia. Data were collected by questionnaire and rhinomanometry preoperatively and 2 and 20 months postoperatively.

RESULTS

Nearly all patients reported an improvement of their nasal breathing, with 68% of them reporting a full and 29% a partial recovery. No significant differences were reported with regard to the response of the allergic versus the vasomotor rhinitis. On average, a definite benefit was observed after 2 weeks. Side effects, such as bleeding, synechia, or atrophic changes of the mucosa, which would have to be treated, were not observed.

CONCLUSION

The new bipolar radiofrequency thermotherapy presents an efficient option for the treatment of turbinate hypertrophy, which meets the requirements for an outpatient treatment.

Radiofrequency volumetric tissue reduction (RFVTR) of inferior turbinates: a new method in the treatment of chronic nasal obstruction

Twenty-two Caucasians (16 male and 6 female) with chronic bilateral nasal obstruction due to hypertrophic inferior turbinates were followed up over a three-month period. They were assessed by clinical examination, as active anterior rhinometry, and acoustic rhinometry before and after topical decongestion, preoperatively and three months after surgery. All patients were treated by application of radiofrequency-volumetric-tissue reduction (RFVTR, or somnoplasty) to both inferior turbinates. Initial postoperative edematous response disappeared during the first week after RFVTR. Three months postoperatively 20 of 22 patients (91%) reported subjective improvement of nasal patency. The average cross-sectional area for both sides of the nasal cavity (measured at the head of the inferior turbinate (C-Notch) before decongestion) increased in 15 of 22 patients (68.2%). This means a significant improvement from 1.24 to 1.49 cm2 for both sides of the nasal cavity (p = 0.0054). We conclude that RFVTR can safely reduce turbinate volume in a precise manner in patients with nasal obstruction due to hypertrophic inferior turbinates.

Argon plasma coagulation for inferior turbinate reduction

Surgical reduction of the inferior turbinate remains a widely used therapy for nasal obstruction caused by hyperplastic turbinates. Current methods are costly and time-consuming, require nasal packing, and cause extended postoperative swelling. Argon plasma coagulation (APC) is a new, innovative technique in otorhinolaryngological surgery that is based on high-frequency electrical current. The current is transmitted through ionized argon gas (plasma) contact-free to the tissue surface and creates a coagulation and devitalization zone with limited penetration. Forty-five patients with nasal obstruction were treated under local anesthesia for reduction of the inferior turbinates with APC. Seventy-six percent of the patients reported an improvement of postoperative swelling within the first week. After 3 months, 86% reported having better nasal airflow than they had before the operation. Macroscopically, after 4 weeks the turbinate was covered by normal mucosa in 51% of the patients. Crust formation was minimal, and no bleeding occurred. Turbinate reduction with APC is an alternative technique with many advantages, and the results are comparable to those of standard techniques. Ninety-five percent of the patients were satisfied with the operation.

Effect of submucosal diathermy to the inferior turbinates on unilateral and total nasal airflow in patients with rhinitis

The efficacy of the controversial treatment of submucosal diathermy to the inferior turbinates (SMDIT) was evaluated objectively. Twenty-seven patients with chronic rhinitis were investigated by hourly posterior rhinomanometry to assess changes in total and minimum (Fmin) and maximum (Fmax) unilateral nasal airflow over 5 h, before and 2-3 months after standardized SMDIT treatment. Nasal airflow was recorded at a sample pressure of 75 Pa and the results are reported as medians with interquartile range. Whilst SMDIT caused a significant 51% increase (p < 0.0001) in total nasal airflow from 246 cm3/s (131) to 371 cm3/s (133) the changes in unilateral airflow provided further evidence which strongly supported the benefits of this operation. Unilateral Fmin significantly increased by 136% (p < 0.0001) from 69 cm3/s (82) to 163 cm3/s (74) and Fmax significantly increased by 23% (p < 0.0001) from 171 cm3/s (74) to 211 cm3/s (59). The effect of surgery was to "splint" to the turbinate in a state of relative vasoconstriction. Our findings therefore provide functional evidence of submucosal fibrosis following SMDIT. The greater percentage change in unilateral Fmin suggests that this parameter is a more sensitive index of the effect of nasal surgery than total nasal airflow measurements. The importance of considering the nose as two separate airways in the evaluation of nasal treatments is emphasized.

[Treatment of the hypertrophic inferior turbinate. 1]

Chronic nasal obstruction is a common disorder, mostly caused by hypertrophied inferior turbinates. If there is inadequate response to conservative medical management, the inferior turbinates should be reduced. The choice of treatment is mainly influenced by whether the nasal airway obstruction is due to hypertrophic mucosa or to an enlarged turbinate bone. The first part of this review describes the various surgical modalities for treatment of swelling of the turbinal mucosa. The indications, advantages, disadvantages, complications, and controversies of each modality (submucous diathermy, cryosurgery, infra-red coagulation, argon-plasma coagulation, radiofrequency, laser surgical techniques) are reviewed and discussed.

A safe, alternative technique for inferior turbinate reduction

OBJECTIVE

Submucous resection of the inferior turbinates is a conventional technique for reducing their size to achieve patent nasal airways in situations where an enlarged turbinate contributes to airway obstruction. Many techniques and complications have been described in the past. We describe a new inferior turbinate reduction technique performed with powered instrumentation and assess its success and complication rates.

STUDY DESIGN

A prospective study of 120 consecutive patients who underwent submucous resection of the inferior turbinates with a microdebrider.

METHODS

Patient questionnaires were used for subjective assessment of symptoms before and after the procedure. We graded each patient's inferior turbinates for size from I to III before and 6 weeks after surgery for objective analysis.

RESULTS

The common complications of standard submucous resection of inferior turbinates include excessive resection, postoperative bleeding, and crusting. The advantage of the microdebrider technique is the precise control of the amount of tissue and location of tissue that is removed on a submucosal plane. The complications encountered with this technique are limited to postoperative bleeding that occurred in 1.6% of patients. There was no crusting or excessive removal of tissue.

CONCLUSION

The results show that submucous resection of inferior turbinates with a microdebrider is a safe method of achieving turbinate size reduction with minimal morbidity.

Laser surgery for allergic rhinitis: the effect on seromucinous glands

Ten patients with perennial allergic rhinitis were subjected to CO2 laser turbinectomy. Tiny (1 mm3) biopsy specimens were taken at the time of surgery and 1 month thereafter. The biopsy specimens were processed for transmission electron microscopy. Also, the activity of succinic dehydrogenase and cholinesterase enzymes was measured. The study showed that laser turbinectomy was followed by reduction in the number and activity of the glandular acini in the laser-treated areas. This reduction is ascribed to the local destructive effect of laser energy on the glandular acini and on the surrounding cholinergic nerve fibers. The enzymatic activity of the cholinergic nerve fibers themselves, however, did not diminish, indicating that laser surgery has no inhibitory effect on the local allergic reaction.

Radiofrequency bipolar submucosal diathermy of the inferior turbinates

Fifty nonatopic patients with chronic hypertrophic rhinitis and suffering from chronic nasal obstruction due to hypertrophied inferior turbinates were subjected to bipolar submucosal diathermy using a radio frequency unit and a bipolar turbinate probe. One year postoperatively, 76% of patients showed significant improvement of their nasal breathing and another 16% reported partial improvement. The minimal cross sectional has also significantly increased from 0.58 +/- 0.05 cm2 to 0.72 +/- 0.04 cm2 and the decongestive effect was statistically significant. Electron microscopic examination of the nasal mucosa at the end of the follow up period revealed intact healthy epithelium as well as intense fibrosis of the underlying stroma. The results of the work showed that bipolar submucosal diathermy is a safe, effective outpatient procedure that does not require nasal packing or expensive instrumentation. The procedure can be repeated, if necessary, according to the patient's needs.

Comparison of carbon dioxide and neodymium: yttrium-aluminum-garnet lasers in surgery of the inferior turbinate

At the Department of Otorhinolaryngology-Head and Neck Surgery of the University of Kiel, 533 patients with hyperplastic inferior turbinates were treated between 1987 and 1994 with various carbon dioxide (CO2) and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser techniques. We report on the therapeutic results of both types of laser turbinectomy and compare their long-term results with those of submucosal diathermy. Among the different techniques, we preferred the following approaches. The CO2 laser technique involved the application of a few laser spots (laser energy density 6,100 J/cm2 per lesion) to the head of the turbinate under the operating microscope. In the Nd:YAG laser procedure, diffuse, low-power irradiation (laser energy density < 53 kJ/cm2) of the entire concha was performed under endoscopic control. The CO2 laser procedure involved little bleeding and hardly any pain. It produced a positive effect after only a few days and required no follow-up treatment. The success of Nd:YAG laser treatment, by contrast, only became evident after weeks or months, due to the slow scarring process. Compared to submucosal diathermy, both laser methods produced better long-term results. Two years postoperatively, the overall success rate, as defined by patient satisfaction, was 79.6% for the CO2 laser, 68.3% for the Nd:YAG laser, and 36% for submucosal diathermy.

Carbon dioxide laser turbinectomy. An electron microscopic study

Ten patients with chronic non-allergic rhinitis and presenting mainly with nasal obstruction due to hypertrophied inferior turbinates were subjected to laser turbinectomy using CO2. Tiny biopsies were taken, at the time of surgery as well as one month later, and were processed for transmission electron microscopy. The ultrastructural observations included: early epithelial loss which was followed by prompt regeneration of healthy epithelium, decreased number and activity of the seromucinous glands, fibrosis of the connective tissue stroma, as well as diminished number and congestion of the cavernous blood spaces. These observations were discussed in view of the excellent clinical response of the patients.

A comparison of laser cautery and sub-mucosal diathermy for rhinitis

A randomized prospective trial was conducted to compare the efficacy of laser cautery against sub-mucosal diathermy to the inferior turbinates in 29 patients with rhinitis. Laser diathermy was performed using an arthroscopic fitment to a CO2 laser. Subjective and objective measurement of airway obstruction were performed, using a linear analogue scale and a nasal peak inspiratory flow meter, before operation and at 3 days and 6 weeks afterwards. In both groups there was a similar and significant improvement in subjective scores at 6 weeks (SMD from 3.6 to 1.8, P less than 0.01; laser from 3.9 to 2.1, P less than 0.001), but only the laser group was significantly better at Day 3 (SMD from 3.6 to 3.5, n.s.; laser from 3.9 to 3.0, P less than 0.05). In addition, there was significantly more general subjective morbidity at Day 3 in the SMD group (P less than 0.01). The objective scores improved equally in both groups but were not significant. We conclude that laser cautery of the inferior turbinate is a superior alternative to SMD for the treatment of rhinitis.

How safe is submucosal diathermy?

Submucosal diathermy (SMD) is a common surgical procedure carried out to improve the nasal airway. A case is presented in which it was followed by profuse epistaxis which required transfusion of 28 units of blood, eight units of fresh frozen plasma (FFP) and four units of platelets within 14 days.

Some observations on submucous diathermy

Submucosal diathermy (SMD) of the inferior turbinates is widely used, although its effect histologically has not been well shown. We attempted to demonstrate the acute histological changes of SMD by performing it immediately prior to inferior turbinectomy. The results found help to explain the unpredictability of producing a clinical response.

Prevention of post-operative intra-nasal adhesions (a new material)

A new material, the wax paper enveloping the Fucidin gauze which is routinely used to pack the nose post-operatively, was utilized in 120 cases considered as 'high-risk' for the formation of post-operative nasal adhesions. This proved to be an inexpensive, simple and effective method when the prevention of the formation of nasal adhesions was the primary goal.