Treatment of hypertrophy of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy

Tissue specific stem cell therapy for airway regeneration

Secondary atrophic rhinitis (AR), a consequence of mucosal damage during nasal surgeries, significantly impairs patient quality of life. The lack of effective, lasting treatments underscores the need for alternative therapeutic strategies. A major impediment in advancing research is the scarcity of studies focused on secondary AR. Our study addresses this gap by developing an animal model that closely mirrors the histopathological changes observed in patients with secondary AR. These changes include squamous metaplasia, goblet cell hyperplasia, submucosal fibrosis, and glandular atrophy. Upon administering human nasal turbinate stem cells embedded in collagen type I hydrogel in these models, we observed ciliary regeneration. This finding suggests the potential therapeutic benefit of this approach. Our animal models not only emulate the clinical manifestations of secondary AR but also serve as valuable tools for evaluating the efficacy of cell-based biotechnological interventions.

Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common condition that is frequently associated with atopic inferior turbinate hypertrophy (ITH) resulting in nasal obstruction. Current guidelines support the use of subcutaneous allergen immunotherapy (SCIT) when patients fail pharmacologic management. However, there is a lack of consensus regarding the role of inferior turbinate reduction (ITR), a treatment that we hypothesize is cost-effective compared with other available treatments.

METHODS

We conducted a cost-effectiveness analysis comparing the following treatment combinations over a 5-year time horizon for AR patients presenting with atopic nasal obstruction who fail initial pharmacotherapy: (1) continued pharmacotherapy alone, (2) allergy testing and SCIT, (3) allergy testing and SCIT and then ITR for SCIT nonresponders, and (4) ITR and then allergy testing and SCIT for ITR nonresponders. Results were reported as incremental cost-effectiveness ratios (ICERs).

RESULTS

For patients who fail initial pharmacotherapy, prioritizing ITR, either by microdebrider-assisting submucous resection or radiofrequency ablation, before SCIT was the most cost-effective strategy. Probabilistic sensitivity analysis demonstrated that prioritizing ITR before SCIT was the most cost-effective option in 95.4% of scenarios. ITR remained cost-effective even with the addition of concurrent septoplasty.

CONCLUSION

For many AR patients who present with nasal obstruction secondary to atopic inferior turbinate hypertrophy that is persistent despite pharmacotherapy, ITR is a cost-effective treatment that should be considered prior to immunotherapy.

LEVEL OF EVIDENCE

NA - Laryngoscope, 2023 Laryngoscope, 134:1572-1580, 2024.

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.

How Does Oxymetazoline Change Nasal Aerodynamics and Symptomatology in Patients with Turbinate Hypertrophy?

OBJECTIVES

Oxymetazoline relieves nasal obstructive symptoms via vasoconstriction, however, the changes in nasal structures and aerodynamics that impact symptoms the most remain unclear.

METHODS

This prospective, longitudinal, and single blinded cohort study applied Computational Fluid Dynamic (CFD) modeling based on CT scans at baseline and post-oxymetazoline on 13 consecutive patients with chronic nasal obstruction secondary to inferior turbinate hypertrophy from a tertiary medical center. To account for placebo effect, a sham saline spray was administered with subject blindfolded prior to oxymetazoline, with 30 min rest in between. Nasal Obstruction Symptom Evaluation (NOSE) and unilateral Visual Analogue Scale (VAS) scores of nasal obstructions were collected at baseline, after sham, and 30 min after oxymetazoline.

RESULTS

Both VAS and NOSE scores significantly improved from baseline to post-oxymetazoline (NOSE: 62.3 ± 12.4 to 31.5 ± 22.5, p < 0.01; VAS: 5.27 ± 2.63 to 3.85 ± 2.59, p < 0.05), but not significantly from baseline to post-sham. The anatomical effects of oxymetazoline were observed broadly throughout the entire length of the inferior and middle turbinates (p < 0.05). Among many variables that changed significantly post-oxymetazoline, only decreased nasal resistance (spearman r = 0.4, p < 0.05), increased regional flow rates (r = -0.3 to -0.5, p < 0.05) and mucosal cooling heat flux (r = -0.42, p < 0.01) in the inferior but not middle turbinate regions, and nasal valve Wall Shear Stress (WSS r = -0.43, p < 0.05) strongly correlated with symptom improvement.

CONCLUSION

Oxymetazoline broadly affects the inferior and middle turbinates, however, symptomatic improvement appears to be driven more by global nasal resistance and regional increases in airflow rate, mucosal cooling, and WSS, especially near the head of the inferior turbinate.

LEVEL OF EVIDENCE

3: Well-designed, prospective, single blinded cohort trial. Laryngoscope, 134:1100-1106, 2024.

Medial Flap Coblation Turbinoplasty Versus Submucous Resection: Outcomes

BACKGROUND

Variable surgical options are available for turbinate reduction. These options include total turbinectomy, partial turbinectomy, submucosal resection, laser surgery, cryosurgery, electrocautery, radiofrequency ablation, and turbinate out-fracture. However, there remains a lack of consensus for the preferred technique.

OBJECTIVES

The aim of this study was to describe the use of coblation for medial flap turbinoplasty procedure. Furthermore, the outcomes of this technique were compared to submucous resection in terms of improvement of patients' symptoms, postoperative bleeding, crusting, and pain scores.

METHODS

This prospective, randomized, comparative surgical trial was conducted on 90 patients. Patients were randomly allocated into 2 groups: medial flap coblation turbinoplasty group (n = 45), and submucous resection group (n = 45). The outcomes of both techniques were analyzed and compared.

RESULTS

Both techniques were equally in alleviating patients' symptoms of nasal obstruction. However, postoperative healing was significantly better in medial flap coblation turbinoplasty group. Additionally medial flap turbinoplasty showed a statistically significant better outcome in terms of postoperative bleeding, crusting and pain scores.

CONCLUSION

Both submucous resection and medial flap coblation turbinoplasty are effective in relieving nasal obstruction and enabling optimal volume reduction with preservation of function of the inferior turbinate. Coblation turbinoplasty has superior outcomes in terms of better healing and less postoperative pain and crusting.

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.

Nasal Airway Function After Prophylactic Intranasal Surgery for Excessive Maxillary Superior Repositioning: A Retrospective Cohort Study Using the Nasal Obstruction Symptom Evaluation Scale

PURPOSE

The purpose of this study is to evaluate the degree of nasal airway function after simultaneous intranasal corrective surgery and bimaxillary surgery in patients with excessive superior maxillary repositioning.

MATERIALS AND METHODS

A retrospective cohort study was conducted on consecutive LeFort I superior repositioning patients who also underwent simultaneous intranasal surgery to prevent airway obstruction between 2015 and 2019. The Nasal Obstruction Symptom Evaluation (NOSE) scale was administered to all participants before the operation and after 1 year.

RESULTS

Fifteen patients (n=12 females; n=3 males) among 440 bimaxillary orthognathic surgery patients were enrolled with inclusion criteria of maxillary impaction between 8 and 12 mm. All subjects underwent at least LeFort I osteotomy, septoplasty, bilateral inferior turbinectomy, and bilateral sagittal split osteotomy. Two patients received custom-made total joint prosthesis. The primary outcome variable investigated was nasal function. The mean preop Nasal Obstruction Symptom Evaluation score was 24.33 and the mean postop score was 5.

CONCLUSIONS

Intranasal procedures performed simultaneously with 8 mm or more maxillary impaction improves postoperative functional outcome in terms of nasal airway patency and breathing. Partial inferior turbinectomies and septoplasty should be performed consistently to avoid nasal obstruction if the impaction of upper jaw exceeds 8 mm.

Outcome of Submucosal Inferior Turbinoplasty in Perennial Allergic Rhinitis

Pharmacotherapy forms mainstay of treatment for allergic rhinitis, and has adverse effects associated with it. Topical steroid therapy is the preferred medication and considered best for long term prophylaxis but with limited compliance. Submucosal turbinoplasty reduces the duration of treatment in comparison to topical steroid which has to be taken daily for a long time. The aim was to evaluate the outcome of submucosal inferior turbinoplasty in patients with perennial allergic rhinitis. A prospective interventional study was performed on 35 patients diagnosed with perennial allergic rhinitis, diagnosed as per ARIA criteria from July 2016 to July 2018. The severity of the disease was assessed using mini RQLQ scoring system. The patients were then subjected to bilateral submucosal inferior turbinoplasty under endoscopic guidance under local anesthesia. 50% significant improvement (p value < 0.05) seen in symptoms were need to blow nose, sneezing, nasal obstruction, nasal discharge, watery eyes, need to rub eye, regular house work, recreational activities, sore eyes, tiredness, irritability and thirst. 100% improvement (p value < 0.05) seen in symptoms were sleep, need to blow nose, sneezing, nasal discharge, watery eyes, need to rub eye, recreational activities and irritability. Nasal obstruction was not severe in 17 (48.5%) patients giving a very good symptom relief and improving quality of life. This is due to reduction in the erectile tissue and roominess in the nasal cavity. All patients with allergic rhinitis with associated hypertrophied turbinates should invariably be given option of inferior turbinoplasty along with proper counselling regarding its advantages and disadvantages.

Surgical Treatment for Empty Nose Syndrome Using Autologous Dermal Fat: Evaluation of Symptomatic Improvement

Background: Empty nose syndrome (ENS) is caused by nasal turbinate surgery. The standard treatment for ENS is an inferior meatus augmentation procedure (IMAP) in which autologous tissue such as auricular cartilage, rib cartilage, or artificial material is transplanted into the nasal cavity. However, some challenges like a very small auricular cartilage are associated with these autologous tissue types. Moreover, since using rib cartilage is a highly invasive technique, the scar on the chest from where the harvesting is done is easily visible, and the artificial material is susceptible to infection. We used autologous dermal fat (ADF) in IMAPs in our study for the following reasons: the quantity of ADF could be increased or reduced as needed, ADF is considered a safer option than rib cartilage because it is harvested from superficial tissue, it is superior in terms of cosmetic appearance to harvested rib cartilage, and it has a lower risk of infection than any artificial material.Objective: The purpose of our study was to investigate the efficacy and safety of IMAPs using ADF.Methods: We included nine patients with ENS who underwent an IMAP using ADF. The patients' backgrounds and responses to the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) were recorded. Changes in each item of the ENS6Q before and after surgery (up to 3 months) were analyzed.Results: The postoperative ENS6Q total score and parameters were significantly better than their preoperative counterparts. Nasal dryness improved slightly less than other symptoms. There were no complications.Conclusions: The IMAP using ADF was effective in improving ENS symptoms; however, some physiological functions were difficult to improve, and dryness persisted. Autologous dermal fat is larger than auricular cartilage, less invasive than rib cartilage, and has a lower risk of infection than artificial material.

Our Septoplasty Results: Evaluation with the Nose Scale

OBJECTIVE

The aim of this study was to evaluate the effectiveness of septoplasty and septoplasty +  bilateral radio frequency ablation of inferior turbinate (b-RFAIT) according to the type of operation, age groups, gender of patients, and the duration of control period by using Nasal Obstruction Symptom Evaluation (NOSE) Scale.

MATERIALS AND METHODS

Prospective observational study was undertaken in the otolaryngology department of a training hospital. Using the NOSE scale, the study prospectively compared the results of septoplasty only and septoplasty with b-RFAIT in the treatment of nasal obstruction caused by the combination of septal deviation and turbinate hypertrophy. Patients were divided into 2 groups. The first group had only septoplasty and the second group had septoplasty with b-RFAIT. General and local anesthesia were applied in both groups. To review clinical success, all patients were controlled at the 1st week, 1st month, and 3rd month.

RESULTS

One hundred seventy-eight adult patients (male/female: 127/51) with chronic nasal obstruction complaint were enrolled in this prospective study. Our data demonstrated significant improvement from baseline after 24 months for the NOSE scores in both the septoplasty and septoplasty + b-RFAIT groups. No statistical difference was noted in the amount of postoperative improvement between the 2 treatment groups (P = 0.306). No significant difference was observed between general and local anesthesia with respect to patients' preop and postop mean scores (P > 0.05). There was a significant difference between the age of patients' postoperative mean (P < 0.001). There were 4 postoperative means with respect to control time. There was an 82.29% decrease in the complaints of patients at 0 to 6 months, 80.51% decrease at 7 to 12months, 76.1% decrease at 13 to 18 months, and 59.67% decrease at 19 to 24 months. Only the last group had a significant difference regarding mean change in scores (P < 0.001).

CONCLUSIONS

This study shows that septoplasty + bilateral turbinate radiofrequency should be applied to patients who suffer from septum deviation with concha hypertrophy. Postoperative NOSE scale shows that the success of operation does not depend on the gender of patients and operation types (general or local anesthesia). We conclude that younger patients (18-40 age) who have obstruction with septal deviation and septum deviation with concha hypertrophy benefit more from operation than older patients do.

Surgical Approaches for Allergic Rhinitis: A Systematic Review Protocol

Background

Exposure to inhaled allergens in patients with allergic rhinitis results in IgE mediated hypersensitivity of nasal mucosa. The mainstay of management is allergen identification and avoidance, pharmacotherapy with antihistamines, corticosteroids and nasal douching and immunotherapy. Patients refractory to medical management can be offered surgical interventions aimed at providing symptom relief. The objective of this review is to evaluate the effectiveness of surgical intervention on functional and symptomatic outcomes in patients with allergic rhinitis that have failed medical management.

Methods

Prospective and retrospective studies that assess the effectiveness of intranasal surgery to include inferior turbinate surgery, posterior nerve resection, vidian neurectomy, septoplasty and endoscopic sinus surgery (ESS) in patients that have failed medical treatment for proven allergic rhinitis. Medline, Web of Science and Embase will be searched for studies published in English from 1990. Two authors will independently screen the search results and assess the full text of potentially relevant studies. Studies that meet the inclusion criteria will be critically appraised and the data will be extracted and synthesised by two authors.

Ethics and Dissemination

Ethical approval was not required for this study as secondary data will be collected. The results will be disseminated through peer-reviewed medical journal.

Systematic Review Registration

This protocol has been registered on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020223773).

Highlights

Allergic rhinitis (AR) is a chronic immune-mediated inflammatory nasal condition with hallmark symptoms of sneezing, nasal obstruction, mucus discharge and anosmia in adverse cases.A plethora of interventions are at the hands of otolaryngologists in order to relieve symptoms of AR, however literature is yet to determine which method is best for patient outcome and quality of life.The primary objective of this study is to convey a systematic qualitative analysis of all the surgical interventions used in AR management.

Inferior Turbinate Reduction during Rhinoplasty: Is There Any Effect on Rhinitis Symptoms?

Introduction  Inferior turbinate surgery is often performed concomitantly with rhinoseptoplasty. As inferior turbinates play a major role in allergic rhinitis, it seems reasonable to suggest that inferior turbinate surgery reduces allergy.

Objective  To assess the impact of nasal turbinate surgery on non-obstructive allergic symptoms (nasal discharge, sneezing, pruritus, and allergic conjunctivitis) and on the use of allergic medication in patients with allergic rhinitis undergoing rhinoseptoplasty.

Methods  Secondary analysis of aggregated data from two randomized controlled trials. Participants with allergic rhinitis aged ≥ 16 years were recruited. Data from two groups were analyzed: patients with rhinoseptoplasty and concomitant turbinate reduction (intervention group) and patients with rhinoseptoplasty only (control group). The 90-day postoperative frequency of non-obstructive allergic symptoms and of nasal steroid and oral antihistamine use were analyzed.

Results  A total of 100 patients were studied. The groups were similar in terms of allergic symptom intensity and mean age. The frequency of non-obstructive allergic symptoms decreased 90 days postoperative in both groups ( p  < 0.01). There was no difference between the groups in the frequency of non-obstructive allergic symptoms at 90 days ( p  = 0.835). Topical nasal steroid and oral histamine antagonist use decreased in the intervention group at 90 days ( p  < 0.05).

Conclusions  Ninety days after the surgery, turbinate reduction performed in association with rhinoseptoplasty did not reduce the frequency of non-obstructive allergic symptoms more than rhinoplasty alone. However, the observed decrease in nasal steroid and oral antihistamine use suggests an impact of turbinate reduction on medication use in patients with allergic rhinitis undergoing rhinoseptoplasty.

Trial Registration  ClinicalTrials.gov database (NCT01457638 and NCT02231216).

Surgical Treatment for the Refractory Allergic Rhinitis: State of the Art

Nasal obstruction is a frequent disorder that interferes with the daily patient’s quality of life. The key element in the pathophysiology of the disorder is the inferior turbinate hypertrophy related to multiple conditions such as allergic rhinitis (AR). Many patients are managed using conventional drug therapies such as antihistamines, decongestants, and intranasal steroid sprays, anticholinergic agents, mast cell stabilizers, and desensitizing vaccines. When traditional therapy failed to relieve AR symptoms, surgical inferior turbinate reduction (ITR) is indicated. A vast variety of surgical techniques have been reported in the literature for AR such as resectioning, coagulating, and laser procedures. We aimed to revise all surgical options in AR management. We confirm that no ideal standard technique for turbinate reduction has been developed so far regarding the multitude of different surgical procedures. Furthermore, no prospective and comparable long-term studies are present in the literature; it is challenging to recommend evidence-based surgical techniques.

Nasal air conditioning following total inferior turbinectomy compared to inferior turbinoplasty - A computational fluid dynamics study

BACKGROUND

The aim of this study was to use computational fluid dynamics (CFD) to investigate the effects on nasal heat exchange and humidification of two different surgical techniques for reducing the inferior turbinate under different environmental conditions.

METHODS

Virtual surgery using two techniques of turbinate reduction was performed in eight nasal airway obstruction patients. Bilateral nasal airway models for each patient were compared: 1) Pre-operative 2) Post inferior turbinoplasty 3) Post total inferior turbinate resection (ITR). Two representative healthy models were included. Three different environmental conditions were investigated 1) ambient air 2) cold, dry air 3) hot, humid air. CFD modelling of airflow and conditioning was performed under steady-state, laminar, inspiratory conditions.

FINDINGS

Nasal conditioning is significantly altered following inferior turbinate reduction surgery, particularly with ITR under cold, dry inspired air (CDA). The degree of impairment is minor under the simulated range of environmental conditions (temperature = 12-40 °C; relative humidity = 13-80%). Streams of significantly colder air are found in the nasopharynx and more prevalent under CDA in ITR. These are related to high velocity flow streams, which remain cool in their centre throughout the widened inferior nasal cavity.

INTERPRETATION

Reduced air-mucosal heat exchange and moisture carrying capacity occurs under cooler temperatures in patients following inferior turbinate surgery. The clinical impact in extremely cold and dry conditions in groups with poor baseline respiratory function, respiratory illness, or endurance athletes is of special interest.

Deviated nose: Physiological and pathological changes of the nasal cavity

Deviated nose is highly challenging in rhinoplasty since the surgeon should consider both aesthetic and functional aspects of the nose. Deviated nose correction is surgically complex, and a thorough understanding of the mechanical and physiological changes of intranasal structures, including the septum and turbinates, is necessary for functional improvement.

Safeness, subjective and objective changes after turbinate surgery in pediatric patients: A systematic review

OBJECTIVE

Inferior turbinates are the main structure related to impaired nasal breathing. When medical treatment fails, surgery is the next step, according to clinical guidelines. However, despite the widespread acceptance of this procedure, there is some controversy about performing it in children.

DATA SOURCES

Pubmed (Medline), the Cochrane Library, EMBASE, Scopus, Science direct, SciELO and Trip Database.

REVIEW METHODS

We looked for articles in which the individual outcome of turbinate surgery in pediatric patients was investigated independently of whether it was the main objective of the study or not.

RESULTS

13 papers (1111 patients) met the inclusion criteria. 6 authors performed diverse objective assessment and 11 authors used subjective scales. All of them found improvement after surgery. Due to the heterogeneity of the methods used, they could not be included in a metanalysis. Eleven out of the 13 authors reported 3.12% complication rates, being minor bleeding the most common (1.30%), followed by crust (0.49%) and pain (0.47%).

CONCLUSIONS

There is a lack of high quality studies in children. Turbinate surgery in children is a safe technique with low complication rates. The available evidence suggests improvement in subjective outcomes after turbinate surgery in children. We cannot make a formal recommendation of a surgical technique in children given the lack of high quality studies, and since comparison between available papers is not possible. Although the evidence at our disposal is weak, it suggests that the safest techniques are MAIT, radiofrequency, coblation and laser.

Prelacrimal approach vs conventional surgery for inverted papilloma in the maxillary sinus

BACKGROUND

The prelacrimal approach, termed endoscopic modified medial maxillectomy (EMMM), has recently been applied for treatment of inverted papilloma (IP) in the maxillary sinus. EMMM provides wider access to the maxillary sinus while preserving the inferior turbinate and nasolacrimal duct.

METHODS

We reviewed patients with IP in the maxillary sinus to compare the surgical results obtained by conventional surgery (ie, endoscopic maxillary sinus antrostomy or in combination with the Caldwell-Luc approach) with those obtained by EMMM.

RESULTS

All patients had a T3 on the Krouse staging system, and the average follow-up time was 46.0 months. Of the 18 patients in the conventional group, recurrence was seen in 3 patients (16.6%). No recurrence was seen in the 27 patients who showed preservation of the inferior turbinate and nasolacrimal duct, and no complications occurred in the EMMM group.

CONCLUSIONS

EMMM is an effective surgical approach that reduces recurrence with fewer complications.

Coblation versus microdebrider-assisted turbinoplasty for endoscopic inferior turbinates reduction

OBJECTIVE

Patients suffering from persistent inferior turbinates hypertrophy refractory to medical treatments require surgical intervention where the main aim is symptomatic relief without any complications. Extraturbinoplasty is one of the preferred procedures for turbinate reduction due to its efficacy in freeing up nasal space by removing the obstructing soft tissue and bone while preserving the turbinate mucosa. We sought to evaluate the effectiveness and safety of microdebrider assisted turbinoplasty (MAT) and coblation assisted turbinoplasty (CAT) performed as an extraturbinoplasty procedure.

METHODS

A prospective randomized comparative trial was conducted among patients with bilateral nasal blockage secondary to inferior turbinates hypertrophy. Patients were randomly assigned to MAT or CAT. An extraturbinal medial flap turbinoplasty was performed for both techniques. Symptom assessment was based on the visual analogue score for nasal obstruction, sneezing, rhinorrhea, headache and hyposmia. Turbinate size, edema and secretions were assessed by nasoendoscopic examination. The assessments were done preoperatively, at 1st postoperative week, 2nd and 3rd postoperative months. Postoperative morbidity like pain, bleeding, crusting and synechiae were documented. The clinical outcomes of both techniques were analyzed using repeated measures ANOVA.

RESULTS

A total of 33 participants were recruited, 17 patients randomized for MAT and 16 patients for CAT. Nasal obstruction, discharge, sneezing, headache and hyposmia significantly reduced from 1st week until 3 months for both procedures. Similar significant reductions were seen for turbinate size, edema and secretions. However, there was no significant difference in symptoms and turbinate size reduction were seen between both groups at the first postoperative week, 2nd and 3rd postoperative months. There was significant longer operating time for CAT when compared to MAT (p = 0.001). The postoperative complications of bleeding, crusting and synechiae did not occur in both groups.

CONCLUSION

Both MAT and CAT were equally effective in improving nasal symptoms and achieving turbinate size reduction in patients with inferior turbinate hypertrophy. Both MAT and CAT offer maximal relieve in patients experiencing inferior turbinates hypertrophy by removing the hypertrophied soft tissue together with the turbinate bone without any complications.

Evaluation of the effect of inferior turbinate outfracture on nasolacrimal transit time by saccharin test

AIM

To evaluate the effect of inferior turbinate outfracture on nasolacrimal transit time by saccharin test.

MATERIALS AND METHODS

Twenty patients who underwent septoplasty + unilateral radiofrequency ablation and outfracture of inferior turbinate were enrolled into study. They had no complaints about their eyes and denied previous ocular surgery. Their nasolacrimal saccharin transit times (NSTTs) were estimated preoperatively and postoperatively in the 1st and 2nd months. The non-fractured side eye was measured only once preoperatively. The fractured-side eye was measured three times. These times were compared statistically.

RESULTS

There were 8 men and 12 women. Mean age was 29.04. Killian incision was used in 14 and hemitransfixion incision was used in 6 patients. Median NSTT was 484, 461, 490 and 446 s for the non-fracture side, preoperatively and postoperatively in the 1st and 2nd months, respectively. There was no statistically significant difference between the two eyes preoperatively, and in the fractured side preoperatively and postoperatively in the 2nd month. There were significant differences between median NSTT in postoperative 1st month and median NSTT in the preoperative measure, and between postoperative 1st and 2nd months (p < 0.05). Median NSST in the 1st month was longer than the others.

CONCLUSION

Outfracture of inferior turbinate had no permanent effect on NSTT 2 months after surgery in patients that had a healthy nasolacrimal system.

Does bilateral inferior turbinate reduction affect long-term quality-of-life outcomes in patients undergoing endoscopic sinus surgery?

BACKGROUND

The objective of this study was to evaluate the impact of bilateral inferior turbinate reduction (BITR) on patient-reported quality of life (QOL) following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS).

METHODS

This was a prospective cohort study. Patients with CRS, who were recruited from 10 different otolaryngologic practices between 2011 and 2014, completed the 22-item Sino-Nasal Outcome Test (SNOT-22), Chronic Sinusitis Survey (CSS), and EuroQol 5 Dimension (EQ-5D) survey at baseline, and at 12, 24, 36, and 48 months after ESS. A total of 113 patients who underwent ESS with BITR were compared to 788 patients who underwent ESS without BITR.

RESULTS

Significant demographic and comorbid differences between BITR and non-BITR cohorts included age (41 vs 49 years, p < 0.0001), presence of asthma (19% vs 36%, p < 0.0001), prior sinus surgery (22% vs 53%, p < 0.0001), and concurrent septoplasty (80% vs 53%, p < 0.0001), respectively. On univariate analysis, patients who underwent ESS with or without BITR were found to have statistically significant improvement in disease-specific (SNOT-22 and CSS) and general (EQ-5D) QOL scores at years 1 through 4 (p < 0.05). On multivariate regression, however, the performance of BITR was not associated with any improvements in these outcome measures.

CONCLUSION

Patients undergoing ESS achieve similar long-term improvement in both disease-specific and general QOL regardless of the performance of concurrent BITR.

Functional and aesthetic results after septorhinoplasty and concomitant radiofrequency of the inferior turbinate: is there a role for patient reported outcome measures (PROMs)?

PURPOSE

Functional and aesthetic results after septorhinoplasty (SRP) are often not clearly demonstrated. There is still an open topic in the literature about analysis of aesthetic, functional results and patients' satisfaction after SRP. The aim of our study is to determine patients' satisfaction after SRP and concomitant radiofrequency of the inferior turbinate (RF) regarding nose appearance and improvement of symptoms, using patient reported outcome measures (PROMs).

METHODS

ROE questionnaire and the NOSE scale were used for a retrospective evaluation to assess patient's satisfaction in 369 patients undergoing SRP surgery from 2003 to 2016. Two additional questions were asked to confirm satisfaction following surgery.

RESULTS

258 patients completed the questionnaires (71.7%). The global average ROE score was 18.14 (75.6%). The percentage of satisfaction of aesthetic result was 87.3%, in particular 10.5% were very happy, 57% very much satisfied and 19.8% moderately satisfied. The global post-operative average NOSE score was 13.1 with the resolution of nasal obstruction in 72.1% cases and a marked improvement in 9.3%. The results of the two additional questions showed that 81% of patients would undergo the procedure again if required and 72.1% of patients were globally satisfied.

CONCLUSIONS

Our study demonstrates the utility of PROMs in evaluating aesthetic and functional results after SRP and simultaneous RF. In our series, the patients undergoing SRP and RF are generally satisfied by the functional and aesthetic results. This kind of assessments should be the most common post-operative evaluation methods in this surgery.

Improvement in minimal cross-sectional area and nasal-cavity volume occurs in different areas after septoplasty and radiofrequency therapy of inferior turbinates

PURPOSE

Septoplasty and radiofrequency therapy for inferior turbinate hypertrophy (RFIT) are common techniques used to improve nasal patency. Our aim was to compare nasal geometry and function using acoustic rhinometry and peak nasal inspiratory flow (PNIF) in three patients groups undergoing surgery for nasal obstruction, and to investigate if the improvement in minimal cross-sectional area (MCA) and nasal-cavity volume (NCV) occurred in different cavity areas in the groups. Finally, we evaluated the correlation between the objective measurements and the patients' assessment of nasal obstruction (SNO).

METHODS

This prospective, observational study investigated 148 patients pre-operatively and 6 months post-operatively. Fifty patients underwent septoplasty (group 1), 51 underwent septoplasty combined with RFIT (group 2), and 47 underwent RFIT alone (group 3). The MCA and NCV were measured at two distances (MCA/NCV_0-3.0 and MCA/NCV_3-5.2), in addition to measuring PNIF and SNO.

RESULTS

Pre-operatively, groups 1 and 2 had narrower MCA_0-3.0 on one side than group 3 (0.31 ± 0.14 and 0.31 ± 0.14) versus (0.40 ± 0.16) cm². Post-operatively, total MCA_0-3.0 and MCA/NCV_3-5.2 increased in group 1. In group 2, MCA/NCV_0-3.0 at the narrow side and total MCA/NCV_3-5.2 increased, while total MCA/NCV_3-5.2 increased in group 3. PNIF improved from 106 ± 49 to 150 ± 57 l/min post-operatively. We found a correlation between increased MCA and NCV and less SNO in the septoplasty group (p < 0.01).

CONCLUSION

Surgery produced an improvement in MCA and NCV in all groups. The improvement occurred in different areas of the nasal cavity in the patient groups. Both anterior and posterior areas increased in the septoplasty groups, while only the posterior area increased in the RFIT group. PNIF improved in all three patient groups, indicating that surgery produced an improvement in nasal patency.

Bipolar Radiofrequency Volumetric Tissue Reduction of Inferior Turbinate: Does the Number of Treatment Sessions Influence the Final Outcome?

Background

The aim of this study was to determine if the number of treatment sessions has an influence on the final intermediate term results of submucosal bipolar radiofrequency volumetric tissue reduction of the inferior turbinate.

Methods

One hundred two patients were enrolled in this study prospectively. The procedure was done using the Coblation (Arthrocare Corp., Sunnyvale, CA). The assessment was done using the 10-cm visual analog scale and acoustic rhinometry. Surgical procedures and preand postoperative assessments were done at the Faculty of Medicine, Cairo University.

Results

Eighty eight percent of our study population achieved final relief of their nasal obstruction, and at least three sessions were needed to maintain the favorable outcome at 1-year follow up.

Conclusion

Increasing the number of bipolar radiofrequency volumetric tissue reduction treatment sessions was associated with better intermediate-term outcome. This was confirmed using subjective and objective methodology.

[Nasal turbinate surgery]

The nose forms the first 8 cm of the upper respiratory tract and is responsible for cleansing, humidification, and temperature control of the supplied air. This is also referred to as conditioning. The nasal valve region, formed by the head of the lower nasal concha, portions of the cartilaginous septum, and the upper lateral cartilage, is responsible for diffusing and accelerating the respiratory airflow. Prerequisite are regular mucociliary clearance and sufficient air passage. Hypertrophy of the lower nasal turbinate is one of the most common causes of symptomatic nasal congestion. In unclear cases, rhinometric procedures are available. In addition to conservative therapy of allergic or vasomotor rhinitis by specific immunotherapy or topical corticoids, numerous interventional procedures are available to reduce conchal tissue. All modern methods have a high degree of protection of the respiratory mucosa in common.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Does the Effect of Inferior Turbinate Outfracture Persist?

BACKGROUND

To resolve nasal obstruction in rhinoplasty, inferior turbinate outfracture is performed widely alone or combined with other procedures. There are conflicting reports on the effect of inferior turbinate outfracture. This study evaluated the persistence of morphologic changes after inferior turbinate outfracture.

METHODS

This retrospective study enrolled 55 patients who underwent inferior turbinate outfracture without septal surgery to approach the sphenoid sinus for brain tumor removal. Coronal paranasal sinus computed tomographic images obtained preoperatively and 6 months postoperatively were compared. The authors measured the shortest distance from the median line to the medial border of the conchal bone and the shortest distance from the medial border of the conchal bone to the lateral nasal line. The authors also gauged the projection angle of the conchal bone and constitutional thickness of the inferior turbinate.

RESULTS

After inferior turbinate outfracture, the shortest distance from the median line to the medial border of the conchal bone increased, and shortest distance from the medial border of the conchal bone to the lateral nasal line decreased. The projection angle decreased significantly by 6 months postoperatively. After outfracture, the thickness of the medial mucosa had increased significantly, wheras the thickness of the conchal bone had decreased significantly (p < 0.05).

CONCLUSIONS

The effect of inferior turbinate outfracture is preserved for at least 6 months. Moreover, compensatory hypertrophy of the medial mucosa develops in the inferior turbinate after outfracture. Therefore, outfracture with medial submucosal volume reduction would be recommended as the best procedure for treating inferior turbinate hypertrophy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Submucosal Inferior Turbinoplasty Using a New Continuous Suction Irrigation Method

Introduction

Numerous surgical techniques for inferior turbinate hypertrophy (ITH) have been reported, each with advantages and disadvantages. Submucosal turbinoplasty with removal of the bony component of the inferior turbinate (IT) is an excellent procedure to expand the nasal cavity. However, this procedure requires a large incision to remove the inferior turbinate bone (ITB) and is associated with hemorrhage, crust formation, and adhesion. A smaller incision would avoid such complications. We developed a continuous suction irrigation method that maintains a clear view of the limited surgical field of the IT. Only a single small incision is needed to insert the rigid endoscope. The surgeon can flush blood with continuous water flow and perform IT surgery without difficulty. We performed this method in 39 cases from January 2016 to January 2017. This video article demonstrates our new submucosal inferior turbinoplasty technique.

Methods

Submucosal turbinoplasty using a continuous suction irrigation method was performed under general anesthesia. An irrigation-suction straw sheath system was used to create an underwater surgical field.

Results

The ITB was removed safely with no severe complications. An expanded common nasal cavity was confirmed postoperatively on computed tomographic images.

Conclusion

We resected the ITB safely using a continuous suction irrigation method without difficulty or complications. We believe that this method may become one of the best surgical options for ITH.

Modified transnasal endoscopic medial maxillectomy through prelacrimal duct approach

OBJECTIVE

We previously reported a modified endoscopic medial maxillectomy (modified transnasal endoscopic medial maxillectomy through prelacrimal duct approach [MTEMMPDA]) to resect inverted papilloma (IP), for which the inferior turbinate (IT) and nasolacrimal duct (ND) can be preserved. MTEMMPDA is a safe and effective method to obtain wide, straight access to the maxillary sinus (MS). However, there are few reported cases of patients who underwent MTEMMPDA, and even fewer of patients who underwent partial osteotomy of the apertura piriformis and the anterior wall of the MS. In this study, we analyzed the outcomes of 51 patients who underwent MTEMMPDA.

STUDY DESIGN

Retrospective review.

METHODS

All patients who underwent MTEMMPDA at our hospital between January 2004 and December 2015 were included in this study.

RESULTS

Fifty-one patients with sinonasal IP in the MS underwent MTEMMPDA. Recurrence was seen in the MS of one patient (follow-up of 2-138 months). The IT remained unchanged in all 51 patients without atrophy. We have not observed epiphora, eye discharge, dry nose, or persistent crusting after this surgery. Although seven patients had numbness around the upper lip after surgery, this had disappeared by 1 year after surgery. Additional partial osteotomy of the apertura piriformis and the anterior wall of the MS were done in eight patients. Deformation of the external nose was not seen.

CONCLUSION

This approach appears to be a safe and effective method to resect IP in the MS, even if there is additional partial osteotomy of the apertura piriformis and the anterior wall of the MS.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2205-2209, 2017.

Computational fluid dynamics and trigeminal sensory examinations of empty nose syndrome patients

OBJECTIVE

The precise pathogenesis of empty nose syndrome (ENS) remains unclear. Various factors such as nasal aerodynamics and sensorineural dysfunction have been suspected, although evidence is limited. This study reported the first examination of both nasal aerodynamics and trigeminal sensory factors in actual ENS patients.

STUDY DESIGN

Prospective case control.

METHODS

We enrolled six patients diagnosed with ENS. Three patients had pre- and post-inferior turbinate (IT) reduction computed tomography scans, which allowed comparison of their nasal aerodynamics changes through computational fluid dynamic (CFD) simulation. Their symptoms were confirmed through Sino-nasal Outcome Test-22, ENS 6-item Questionnaire, acoustic rhinometry, and rhinomanometry findings. Nasal trigeminal sensitivity that potentially mediates their perception of airflow was assessed via menthol lateralization detection thresholds (LDT) and compared with 14 healthy controls.

RESULTS

Post-surgical reductions in nasal resistance were observed and significantly lower than normal (P < 0.05). Computational fluid dynamic analysis showed that, paradoxically for all ENS patients, IT reduction did not draw more airflow to the airway surrounding the ITs, but rather resulted in nasal airflow forming into a narrow jet toward the middle meatus region, leaving the airway surrounding the IT with significantly reduced airflow intensity and air-mucosal interactions (inferior region flow percentage reduced from 35.7% ± 15.9% to post-surgery 17.7% ± 15.7%, P < 0.05; inferior wall-shear-stress reduced from 7.5 ± 4.2 × 10^-2 Pa to 3.4 ± 3.1 × 10^-2 Pa, P < 0.01). Empty nose syndrome patients also had significantly impaired menthol LDT compared to healthy controls (P < 0.005).

CONCLUSION

The results indicated that a combinatory of factors, including paradoxically distorted nasal aerodynamic, impaired sensorineural sensitivity, and potential predisposing conditions, may contribute to the development of ENS.

LEVEL OF EVIDENCE

3b. Laryngoscope, 127:E176-E184, 2017.

Three different turbinoplasty techniques combined with septoplasty: Prospective randomized trial

OBJECTIVES/HYPOTHESIS

Septal deviation and hypertrophic inferior turbinates are a frequent cause of nasal breathing disorders. The goal of this study was to prove the effectiveness and safety of three current turbinoplasty techniques.

STUDY DESIGN

This is a prospective, three-arm, single-blinded, single-center, randomized controlled trial.

METHODS

Sixty patients were randomly assigned to either anterior turbinoplasty (ATP) (n = 20), radiofrequency ablation (RFA) (n = 19; Celon Pro Breath), or novel submucous radial diode laser ablation (DLA) (n = 21; ELVeS Radial PainLess, wavelength = 1,470 nm), each in combination with standard septoplasty. Acoustic rhinometry, rhinomanometry, subjective nose questionnaire, and saccharin test served as outcome parameters for preoperative and 3-month, 1-year, and 2-year postoperative examinations.

RESULTS

After 3 months 47/60 patients were evaluated, 28/60 patients were evaluated after 1 year, and 26/60 patients were evaluated in the 2-year follow-up visit. An improvement of nasal breathing was observed in all three groups in all follow-up visits. The increase of endonasal volume 2 (volume between the nasal valve and body of the inferior turbinate) was statistically significant in the ATP and RFA group after 3 months and 2 years, and in the RFA group also after 1 year. The DLA group failed to reach significance level in all follow-up visits. Subjective evaluation of nasal breathing improved in all three groups.

CONCLUSIONS

In this trial, three different current techniques of turbinate surgery in combination with standard septoplasty were effective for the improvement of nasal breathing. The ATP and RFA techniques were more effective in the long term than DLA.

LEVEL OF EVIDENCE

1b. Laryngoscope, 2016 127:303-308, 2017.

Ultrastructural regenerating features of nasal mucosa following microdebrider-assisted turbinoplasty are related to clinical recovery

BACKGROUND

The nasal mucosa plays a key role in conditioning the inhaled air and in regulating the immune response. These functions led many authors to recommend mucosal sparing techniques for the surgical management of inferior turbinate hypertrophy. However, the histological modifications of chronic diseases retain the inflammatory activity and prevent the nasal physiology restoration. It has been proved that the basal cells of the nasal mucosa are able to proliferate and to repair after cold-knife incision. The aim of this study was to demonstrate that the healing process after removal of the inferior turbinate mucosa with cold techniques results in a complete structural restoration.

METHODS

A prospective study was performed in 18 patients who underwent Microdebrider inferior turbinoplasty (cold technique). Subjective and objective improvement of nasal patency was evaluated with visual analogue scale, rhinomanometry, videoendoscopy and mucociliary transport test. Pre- and post-operative biopsy specimens were taken from 7 patients to evaluate the healing process. Two samples were taken from two healthy patients as control. The specimens were processed for transmission electron microscopy analysis.

RESULTS

Videoendoscopy showed reduction of lower turbinate after surgery. Nasal patency augmented and no adverse consequences were observed. After 4 months the nasal mucosa showed normal appearance, with restoration of the pseudostratified ciliated pattern, intercellular connections and normal cellular morphology. Fibrosis and submucosal edema disappeared. At longer time after operation (4 years) clinical improvement was confirmed.

CONCLUSIONS

The total removal of the nasal mucosa with cold techniques results in a complete restoration of the normal structure and permanent resolution of the chronic inflammation typical of hypertrophic rhinopathy.

Development and Validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale

OBJECTIVE

The study goal was to validate a disease-specific health status instrument for use in patients with nasal obstruction.Design, settings, and patients The study consisted of a prospective instrument validation conducted at 4 academic medical centers with 32 adults with nasal septal deformity.

METHODS

Prospective instrument validation occurred in 2 stages. Stage 1 was the development of a preliminary (alpha-version) instrument of potential items. Stage 2 was a test of the alpha-version for item performance, internal consistency, and test-retest reliability; construct, discriminant, criterion validity, and responsiveness; and creation of the final instrument.

RESULTS

Items with poor performance were eliminated from the alpha-version instrument. In testing the final instrument, test-retest reliability was adequate at 0.702; internal consistency reliability was also adequate at 0.785. Validity was confirmed using correlation and comparison analysis, and response sensitivity was excellent.

CONCLUSIONS

The Nasal Obstruction Symptom Evaluation Scale is a valid, reliable, and responsive instrument that is brief and easy to complete and has potential use for outcomes studies in adults with nasal obstruction.

The Evaluation of Relationship Between Body Mass Index and Nasal Geometry Using Objective and Subjective Methods

INTRODUCTION

It is known that obesity causes obstructive sleep apnea syndrome by increasing upper airway resistance. Also, obese patients are admitted to the ear, nose, and throat clinic very often because of nasal obstruction complaint. The aim of this study is to identify the change and relation among body mass index (BMI), nasal resistance, reduction in nasal ariflow, nasal anatomy, and patients' subjective complaints.

MATERIAL AND METHOD

A total of 67 patients admitted to our clinic between August 2013 and January 2014 were included in the study.The study group comprised 33 patients who had a chief complaint-nasal obstruction and the other group consisted of 34 patients who had no complaint and nasal pathology. Both the groups were checked with acoustic rhinometry (AR), active anterior rhinomanometer, nasal obstruction symptom evaluation (NOSE), and visual analog study (VAS) questionnaire.

RESULTS

There is a significant statistical correlation between the body mass increase and VAS and NOSE score increase (P < 0.05). But the authors did not find any statistically significant relation between BMI and total inspiratory and expiratory MR and MF measured by anterior active rhinomanometer and left and right nasal cavity MCA, and volume measured by acoustic rhinometery (P > 0.05).

CONCLUSIONS

Contrary to belief, obesity does not change the nasal resistance, airflow, and anatomy but it can cause subjective nasal complaints.

Comparative study between partial inferior turbinotomy and microdebrider-assisted inferior turbinoplasty

PURPOSE

The purpose of our study was to compare the inferior turbinotomy and the microdebrider-assisted inferior turbinoplasty in patients with hypertrophy of the inferior turbinate.

MATERIAL AND METHODS

We carried out a retrospective review of 205 patients, 96 women and 109 men, with a mean age of 48 years, operated on for hypertrophy of the inferior turbinate between May 2005 and May 2012. Forty-seven patients were excluded from our study because in these patients, nasal obstruction was caused by a specific pathologic condition (allergy, tumors or polyps, recurrent rhinosinusitis, etc). The remaining 158 patients were randomly assigned to undergo partial inferior turbinoplasty through the use of microdebrider (group A, n = 79) or partial inferior turbinotomy (group B, n = 79). Surgical outcome was evaluated according to 4 distinct parameters: nasal endoscopic findings, nasal subjective symptoms, anterior rhinomanometry, and nasal mucociliary transport time. These evaluations were made before surgery and 1 week and 3 months after surgery. The follow-up was a minimum of 24 months and a maximum of 60 months, with a mean follow-up of 42 months.

RESULTS

Turbinate edema and secretions decreased significantly (P < 0.05) in groups A and B 3 months after surgery. In group A, crusting was not observed after surgery. In group B, crusting had increased significantly (P < 0.005) 1 week after surgery and then decreased significantly at the third month after surgery. Subjective nasal symptoms including nasal obstruction, sneezing, snoring, itchy nose, hyposmia, headache, and dryness were significantly improved in both groups from the third month after surgery (P < 0.05). Rhinomanometric measurements demonstrated a significant nasal flow increase at 3 months (P < 0.05). The mean nasal mucociliary transport time slightly increased in both groups 1 week after surgery, and then restabilized to preoperative values at the third-month follow-up in both groups (difference not significant).

CONCLUSIONS

Microdebrider-assisted inferior turbinoplasty and partial inferior turbinotomy are very effective surgical techniques for solving hypertrophy of the inferior turbinates and therefore related problems of nasal obstruction. Microdebrider-assisted inferior turbinoplasty compared to partial inferior turbinotomy ensures a greater preservation of the nasal mucosa to prevent nasal bleeding.

Correction of Symptomatic Chronic Nasal Airway Obstruction in Conjunction With Bimaxillary Orthognathic Surgery: Does It Complicate Recovery and Is It Effective?

PURPOSE

The purpose of this study was to assess the safety and efficacy of intranasal procedures carried out simultaneously with bimaxillary orthognathic surgery.

MATERIALS AND METHODS

The authors executed a retrospective cohort study derived from patients treated by a single surgeon at 1 institution from 2004 through 2013 with a minimum follow-up of 1 year (range, 1 to 10 yr). An index study group consisting of a consecutive series of patients with symptomatic chronic obstructive nasal breathing (CONB) and a bimaxillary developmental dentofacial deformity (DFD) also involving the chin were identified. They underwent a minimum of: Le Fort I osteotomy, bilateral sagittal ramus osteotomies, septoplasty, inferior turbinate reduction (ITR), and osseous genioplasty. Study variables included age at operation, gender, pattern of presenting DFD, presence of obstructive sleep apnea, segmentation of the maxilla, and airway management. The primary outcome variable studied was residual CONB.

RESULTS

During the study period, 262 patients met the inclusion criteria. Their age at operation averaged 25 years (range, 13 to 63 yr) and 134 were female (51%). The major patterns of presenting DFD included long face (29%) and maxillary deficiency (25%). No patients required nasal packing, reintubation, tracheostomy, or blood transfusion. In 6 of the 262 patients (2%), the intranasal procedures did not resolve nasal breathing difficulties. In these patients, procedures recommended included synechiae release (n = 3), revision septoplasty (n = 3), and further ITR (n = 4). An association between age at time of surgery and non-segmental Le Fort I osteotomy with the occurrence of residual nasal obstruction was confirmed.

CONCLUSIONS

When completing septoplasty and ITR through a Le Fort I, airway management need not be altered from standard protocol. The management of CONB in conjunction with orthognathic surgery is highly effective, with few complications. Non-segmental Le Fort I in patients at least 40 years of age is more likely to be associated with residual CONB, but the incidence remains low.

Clinical Consensus Statement

Objective

To develop a clinical consensus statement on septoplasty with or without inferior turbinate reduction.

Methods

An expert panel of otolaryngologists with no relevant conflicts of interest was assembled to represent general otolaryngology and relevant subspecialty societies. A working definition of septoplasty with or without inferior turbinate reduction and the scope of pertinent otolaryngologic practice were first established. Patients 18 years and older were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.

Results

The group defined nasal septoplasty as a surgical procedure designed to correct a deviated nasal septum for the purpose of improving nasal function, form, or both. After 2 iterative Delphi method surveys, 20 statements met the standardized definition of consensus, while 13 statements did not. The clinical statements were grouped into 8 categories for presentation and discussion: (1) definition and diagnosis, (2) imaging studies, (3) medical management prior to septoplasty, (4) perioperative management, (5) surgical considerations, (6) adjuvant procedures, (7) postoperative care, and (8) outcomes.

Conclusion

This clinical consensus statement was developed by and for otolaryngologists and is intended to promote appropriate and, when possible, evidence-based care for patients undergoing septoplasty with or without inferior turbinate reduction. A complete definition of septoplasty with or without inferior turbinate reduction was first developed, and additional statements were subsequently produced and evaluated addressing diagnosis, medical management prior to septoplasty, and surgical considerations, as well as the appropriate role of perioperative, postoperative, and adjuvant procedures, in addition to outcomes. Additionally, a series of clinical statements were developed, such as “Computed tomography scan may not accurately demonstrate the degree of septal deviation,” “Septoplasty can assist delivery of intranasal medications to the nasal cavity,” “Endoscopy can be used to improve visualization of posterior-based septal deviation during septoplasty,” and “Quilting sutures can obviate the need for nasal packing after septoplasty.” It is anticipated that the application of these principles will result in decreased variations in the care of septoplasty patients and an increase in the quality of care.

The effect of OK-432 (Picibanil) injection on the histopathology of nasal turbinate

OBJECTIVE

This study aimed to assess the histopathological effect of OK-432 (Picibanil) on rabbit nasal turbinates.

METHODS

A total of 21 rabbits were divided into 3 treatment groups and various parts of both nasal turbinates were injected with 0.5 ml OK-432, 0.2 ml OK-432 or 0.6 ml saline (control). Bilateral nasal turbinates were later excised and studied under light microscopy to assess any histopathological changes.

RESULTS

Animals in the 0.2 ml and 0.5 ml OK-432 groups exhibited mild ciliary loss, goblet cell loss and epithelial damage, and a marked increase in inflammatory cell infiltration, submucosal vascularisation and fibrosis. There was a significant difference in histopathological changes between the two OK-432 treated groups. In addition, each OK-432 treated group had significantly more inflammatory cell infiltration, increased submucosal vascularisation and fibrosis compared with controls.

CONCLUSION

The marked fibrosis observed in OK-432-injected turbinates may be responsible for a reduction in turbinate size.

Lobular capillary hemangioma formation: An unusual complication of submucous resection with power instrumentation of the inferior turbinate

Submucous resection with powered instrumentation (SRPI) is an effective surgical method to achieve inferior turbinate (IT) reduction with minimal morbidity. We describe a series of two cases of capillary hemangioma (pyogenic granuloma) that developed in the posterior third of the IT as a late complication after SRPI.

Managing turbinate hypertrophy: coblation vs. radiofrequency treatment

The role of inferior turbinate hypertrophy in the reduction of nasal airflow is well established. Although chronic nasal obstruction is not life- threatening, it significantly impairs patients' quality of life, affecting many aspects of daily activities; therefore, patients seek medical intervention. 40 patients were selected (27 males and 13 females) between 27 and 64 years of age with a symptom of nasal obstruction. The patients were divided in two groups: Group 1: coblation, 25 patients (18 males and 7 females); Group 2: radiofrequency, 15 patients (7 males and 6 females). These 40 patients were followed for 3 years. Patients were analyzed using both subjective and objective methods. The visual analog scale (VAS) subjective data and objective data including both active anterior rhinomanometry and acoustic rhinometry were recorded and analyzed. Data were collected pre-operatively and at 1 and 3 years post-operatively. According to our data, both coblation and radiofrequency turbinate reduction benefit patients with good results. The complications, found during the follow-up, are limited to minimal bleeding and crusting. Coblation and radiofrequency were significantly less painful than others procedures during the early post-operative period. In our study, both coblation and radiofrequency provide an improvement in nasal airflow with a reduction in nasal obstructive symptoms in the short term, but their efficacy tended to decrease within 3 years.

Surgery for allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a highly prevalent disorder that significantly impacts quality of life and affects millions of people annually. The most bothersome complaint is nasal obstruction, which is most commonly due to inferior turbinate hypertrophy.

METHODS

This work presents a review of the literature and an overview of operative techniques.

RESULTS

A variety of methods are available for addressing inferior turbinate hypertrophy in patients afflicted with AR. Although no single modality has been defined as the gold standard for treatment, the otolaryngologist should be familiar with an armamentarium of surgical techniques.

CONCLUSION

The inferior turbinate is the initial deposit point for allergens and undergoes dynamic changes through the allergic cascade, which results in nasal obstruction. Targeting the inferior turbinate to augment the nasal airway is the mainstay of surgical treatment in AR. Judicious technique and a mucosal sparing philosophy are necessary to maximize outcomes and improve quality of life.

Turbinoplasty with quantic molecular resonance in the treatment of persistent moderate-severe allergic rhinitis: Comparative analysis of efficacy

BACKGROUND

Allergic rhinitis (AR) presents as the main and most invasive symptom in the blocking of the nose. This condition is almost always related to hypertrophy of the inferior turbinates. When the medical treatments are found to be insufficient to solve the obstructive symptom of the patient, the quality of life is considerably impaired and it is often necessary to submit the patient to a surgical approach. In the present study we aimed to establish the efficacy and safety of a new technique recently introduced for the shrinkage of hypertrophic turbinates using a specific device, based on a new radiofrequency energy that does not produce thermal mucosal damage, viz., quantic molecular resonance (QMR) in a group of patients with persistent moderate-severe allergic rhinitis, in addition to standard medical treatment (nasal steroid and oral antihistamine).

METHODS

All patients were randomly assigned to two homogeneous groups (group A, control subjects; group B, treated patients); each group included 145 individuals. During the study, both groups received standard medications (ebastine, 10-mg tablet, and budesonide nasal spray at 100 micrograms/nostril per day) for 90 days. Before the medical treatment, patients in group B underwent inferior endoscopic turbinoplasty using QMR. All of the patients enrolled in this study were submitted to a complete otorhinolaryngologic evaluation with objective clinical examination (basal rhinomanometry, nasal provocation test rhinomanometry, and mucociliary transport time), endoscopy, and questionnaires (22-item Sino-Nasal Outcome Test and visual analog scale for nasal symptoms).

RESULTS

Greater efficacy has been achieved using a combined approach with the association of medical and QMR treatment, compared with medical treatment alone, in the control of AR associated with hypertrophy of the inferior turbinates, in particular in the reduction of turbinate volume at rhinoendoscopy.

CONCLUSION

QMR inferior turbinoplasty, in conjunction with medical therapy, improves the nasal flow, without any thermal mucosal damage, more effectively when compared with medical treatment alone in persistent moderate-to-severe AR. In particular, local reactivity, as measured with nasal provocation test, was noticeably reduced.

Radiofrequency Coblation Versus Intramural Bipolar Cautery for the Treatment of Inferior Turbinate Hypertrophy

OBJECTIVE

Compare intramural bipolar electrocautery and radiofrequency coblation in the treatment of inferior turbinate hypertrophy with regards to objective and subjective improvement in nasal obstruction, rate and type of complications, experience during the procedure, and rate of recovery.

STUDY DESIGN

Prospective, single-blinded study.

SETTING

Single tertiary medical center from 2008 to 2010.

SUBJECTS AND METHODS

Forty-one adult patients with inferior turbinate hypertrophy refractory to medical management were treated with radiofrequency coblation in one nostril and intramural bipolar cautery in the other. Subjective and objective data, including use of a Visual Analog Scale (VAS) for subjective outcomes, acoustic rhinometry, and nasal endoscopy, were then obtained from each patient comparing the 2 techniques.

RESULTS

Radiofrequency coblation was significantly less painful than intramural bipolar cautery during the procedure (P = .03) and during the early postoperative period (P < .02) and produced less crusting at 3 weeks (P = .009). Both interventions were similar in subjective and objective improvements in nasal obstruction as measured by acoustic rhinometry and subjective VAS outcomes.

CONCLUSION

Radiofrequency coblation seems to offer an equivalent alternative to bipolar electrocautery for the treatment of inferior turbinate hypertrophy with less discomfort during the procedure and early post-operative period.

Feasibility of septal body volume reduction for patients with nasal obstruction

OBJECTIVE

Septal body hypertrophy, like inferior turbinate hypertrophy, can result in changes to the nasal cross-sectional area and resistance to airflow. The aim of this study is to evaluate the efficacy of septal body volume reduction (SBVR) for the treatment of septal body hypertrophy in patients with nasal obstruction.

STUDY DESIGN

Prospective randomized study.

METHODS

The study was conducted on two groups (51 patients) with symptoms and signs of nasal obstruction associated with septal body and inferior turbinate hypertrophy that were refractory to medical therapy. In the turbinoplasty only (ITR) group (n = 25), conventional turbinoplasty was only performed on the inferior turbinate. In the septal body reduction (SBR) group (n = 26), concurrent bilateral microdebrider-assisted SBVR was performed during the turbinate surgery.

RESULTS

The nasal symptoms, including nasal obstruction, rhinorrhea, itching, and sneezing, had significantly improved at 3 months after treatment in both groups (P < 0.001). Improvement of nasal obstruction in the SBR group was greater than that in the ITR group at 3 months (P < 0.05). Acoustic rhinometry demonstrated a significant increase in the cross-sectional area and nasal volume in both groups 3 months after surgery. The postoperative change in nasal volume was higher in the SBR group (P < 0.05). No adverse reactions such as bleeding, infection, adhesions, or olfactory changes were encountered in the SBR group.

CONCLUSIONS

Combined SBVR and turbinoplasty appears to be more effective than turbinoplasty alone for the treatment of nasal obstruction in patients with inferior turbinate and septal body hypertrophy.

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.

Effects of radiofrequency thermal ablation on the nasal cycle measured using rhinomanometry

OBJECTIVE

This study was designed to research the effects of radiofrequency thermal ablation (RFTA) surgery on the nasal cycle, with anterior rhinomanometry being used for assessment.

METHODS

Thirty patients with inferior concha hypertrophy and 13 healthy volunteers were included in this study. An anterior rhinomanometry was performed on each of the patients before surgery and at 1 month and 6 months after surgery, and on the volunteers in the control group, simultaneously.

RESULTS

Nineteen of the 30 patients and 8 of the 13 healthy participants showed a distinct type of nasal cycle at different periods of measurement. The mean of the total nasal airflow of the patients was lower before RFTA surgery but increased at a rate of 71.07%, closer to the value of the control group, after RFTA surgery. After RFTA, the unilateral nasal airflow (fmin and fmax) values increased at ratios of 22.36% and 94.44%, respectively. The amplitude (fmax-fmin) showed a statistically significant decrease in the postoperative period (108.43 ± 54.37), when compared with that of the preoperative period (202.80 ± 81.24) (P < .01).

CONCLUSION

We conclude that the RFTA is a useful method for treating inferior concha hypertrophy, because it positively affects the nasal physiology, increasing the total nasal airflow without changing the nasal cycle time.