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Powered Inferior Turbinoplasty

BIBLIOGRAPHY WITH ARTICLE SUMMARIES

TABLE OF CONTENTS
POWERED INFERIOR TURBINOPLASTY
Long-Term Outcomes of Microdebrider-Assisted and Radiofrequency-Assisted
Turbinoplasty: Randomized Study (Huang et al, 2009)...................................................................................1
Ten Years of Experience with an Inferior Turbinate Debriding Technique
(Yez and Mora, 2008)..................................................................................................................................................2
Radiofrequency vs Microdebrider Technique for Treating Inferior Turbinate Hypertrophy:
a Randomized Study (Kizilkaya et al, 2008)...........................................................................................................2
Effects of Microdebrider-Assisted Inferior Turbinoplasty on Nasal Resistance and
Quality of Life in Patients with Allergic Rhinitis (Huang and Cheng, 2006). ..............................................3
Radiofrequency vs Microdebrider-Assisted Partial Turbinoplasty (Lee and Lee, 2006)......................4
Modified Endoscopic Turbinoplasty, Submucosal Powered Turbinoplasty, and
Submucosal Electrocautery: Randomized Trials (Sacks et al, 2005)...........................................................5
Inferior Turbinate Reduction with the Microdebrider (Friedman, 2005). ................................................6
Intraturbinate Stroma Removal with the Microdebrider in Chronic Hypertrophic Rhinitis
(Yez, 1998)...................................................................................................................................................................6
Powered Instrumentation for Submucous Resection of the Inferior Turbinates
(Friedman et al, 1999).....................................................................................................................................................7
Mucosal-Sparing Techniques for Office Treatment of Inferior Turbinate Hypertrophy
(Lee et al, 2001). ..............................................................................................................................................................8

OTHER INFERIOR TURBINOPLASTY TECHNIQUES


Histopathological Changes after Inferior Turbinate Reduction Using Coblation Method
(Berger et al, 2008)..........................................................................................................................................................9
Number of Treatment Sessions for Bipolar Radiofrequency Volumetric Inferior
Turbinate Reduction (Atef et al, 2006)................................................................................................................ 10
Radiofrequency for Inferior Turbinate Hypertrophy and Use of a Preoperative Topical
Vasoconstrictor Drop Test (Yilmaz et al, 2006). ................................................................................................ 11
Radiofrequency Treatment of Inferior Turbinate Hypertrophy: Long-Term Results
(Porter et al, 2006)........................................................................................................................................................ 11
Radiofrequency Turbinoplasty vs Traditional Surgery (Cavaliere et al, 2005)....................................... 12

Randomized, Long-Term Trial of Six Treatments for Inferior Turbinate Hypertrophy


(Pssali et al, 2003). ...................................................................................................................................................... 13
Coblation Inferior Turbinate Reduction (Bhattacharyya and Kepnes, 2003)............................................. 14
Submucosal Diathermy for Chronic Nasal Obstruction Due to Turbinate Enlargement
(Fradis et al, 2002). ....................................................................................................................................................... 14
Biopolar Radiofrequency Cold Ablation for Inferior Turbinate Hypertrophy
(Bhattacharyya and Kepnes, 2002). ............................................................................................................................ 15
Radiofrequency for Turbinate Hypertrophy (Coste et al, 2001)................................................................ 15
Radiofrequency Treatment of Turbinate Hypertrophy: Randomized Trial
(Nease and Krempl, 2004). .......................................................................................................................................... 16
Radiofrequency Volumetric Tissue Reduction for Turbinate Hypertrophy (Li et al, 1998). .......... 16
Submucosal Bipolar Radiofrequency Ablation of Inferior Turbinates (Bck et al, 2002)................ 17

RELATED TOPICS
Subjective Assessment of Unilateral Nasal Obstruction (Clarke et al, 2006)........................................ 18

POWERED INFERIOR TURBINOPLASTY


Long-Term Outcomes of Microdebrider-Assisted and Radiofrequency-Assisted
Turbinoplasty: Randomized Study
The aim of the study described in this article was to compare long-term results of two mucosasparing techniques for treating inferior turbinate hypertrophy: microdebrider-assisted inferior
turbinoplasty (MAIT) and radiofrequency-assisted inferior turbinoplasty (RAIT). The investigation enrolled 120 adult patients with chronic nasal obstruction and rhinitis unresponsive
to medical treatment who were randomly assigned to undergo either MAIT or RAIT (n = 60
in each group). Patients with bony turbinate hypertrophy were excluded from the study.
The MAIT operations were done with a 2.9 mm-diameter microdebrider tip (Medtronic ENT,
Jacksonville, FL) rotating continuously in a circular pattern at 3000 rpm. The RAIT procedures
used a Coblator Plasma Surgery System (ArthroCare, Austin, TX) at an output power level of
four (168 to 182 Vrms).
None of the patients in either surgical group had active bleeding during or after their procedure. Seven patients in the MAIT group and none in the RAIT group had mucosal tears, but
there was no loss of mucosa in either group. Postoperative crusting and synechia developed in
seven patients in the MAIT group. No patient in the study had onset of atrophic rhinitis during
the follow-up period.
Follow-up assessments were conducted 6 months, and 1, 2, and 3 years postoperatively. All
patients in both groups returned for their 6-month and 1-year follow-up visits. At 2 and 3 years,
the follow-up rate ranged from 89% to 95%. All follow-up visits included an evaluation of the
severity of the patients symptoms (nasal obstruction, sneezing, rhinorrhea, and snoring) that
used a visual analogue scale, active anterior rhinomanometry to measure total nasal resistance, and saccharin testing to assess nasal mucociliary transport.
The study found that, compared with preoperative findings, symptom scores, mean total nasal
resistance value, and mean saccharin transit time in the MAIT group had improved significantly
at all postoperative assessment times (P < 0.05). In the RAIT group, significant improvements
were observed at 6 months and 1 year but not at 2 and 3 years. When results in the two groups
were compared, none of the values for the assessed variables were significantly different at 6
months. At 1, 2, and 3 years, however, all results for both the subjective and objective variables
were significantly better in the MAIT group (P < 0.05).
The authors of the article suggest that the difference in results between the MAIT and RAIT
groups may have been due to the fact that the thermal injury and fibrosis or shrinkage of the
submucosal turbinate tissue provided by RAIT could be insufficient in patients with prolonged
hypertrophy, thereby leading to unsatisfactory volume reduction at 1 year and subsequently. The
authors also comment that MAIT probably improved the patients long-term symptoms more
effectively than did RAIT because MAIT removed submucosal tissue more thoroughly, including
reducing the number of inflammatory cells and damage to the postnasal nerve branch.
Liu C-M, Tan C-D, Lee F-P, Lin K-N, Huang H-M. Microdebrider-assisted versus radiofrequency-assisted
inferior turbinoplasty. Laryngoscope 2009;119:414-8.

Ten Years of Experience with an Inferior Turbinate Debriding Technique


This article describes a prospective cohort study of the efficacy and long-term (10-year)
outcome of the submucosal stroma debriding (SSD) technique in 341 patients with nonallergic
chronic hypertrophy of the inferior turbinate unresponsive to medical therapy. The SSD operation involved a 4 mm incision over the head of the inferior turbinate, creation of a submucosal
tunnel along the turbinate with use of an elevator, and submucosal use of a debrider to
remove the stroma and reshape the bone from the caudal to the posterior portion of the turbinate. Patients were evaluated 6 months and 1, 2, 5, and 10 years after surgery by using nasal
endoscopy, acoustic rhinometry, measurements of saccharin transit time, and visual analog
scales for assessment of symptoms.
One patient had bleeding requiring cauterization after an SSD procedure; no complications
were observed in the other 340. At each of the five follow-up assessments, more than 90% of
patients had no nasal obstruction. At 10 years postoperatively, 91% were symptom-free, 5%
had some symptoms, and 4% had recurrence of obstruction. Compared with baseline values,
there were significant decreases in turbinate engorgement/size and mucociliary saccharin
transit times and significant increases in nasal flow during follow-up. A control group of volunteers with no history of nasal or sinus problems or nasal surgery had no significant changes in
any of these variables during the 10-year follow-up period.
The authors comment that the longlasting effects of SSD are probably due not only to volumetric
changes but also to a reduction in the capacity of the inferior turbinate to engorge in response to
environmental stimuli. The authors conclude that the SSD method has several advantages: minimal
invasiveness, cost savings (the debrider blade is cheaper than radiofrequency or Coblation
applicators), simplicity, and more effective and controlled anterior-to-posterior reduction of the
turbinate stroma and bone without damage to the respiratory epithelium.
Yaez C, Mora N. Inferior turbinate debriding technique: ten-year results. Otolaryngol Head Neck Surg
2008;138:170-5.

Radiofrequency vs Microdebrider Technique for Treating Inferior Turbinate


Hypertrophy: a Randomized Study
The goal of this prospective randomized study was to compare the efficacy of submucosal
temperature-controlled radiofrequency tissue-volume reduction (TCRFTVR) and submucosal
resection with a microdebrider (SMRM) in the treatment of nonallergic chronic inferior turbinate hypertrophy. The 30 patients in the study were treated with TCRFTVR on one side and
SMRM on the other. The radiofrequency energy was delivered to three different sites on each
turbinate. The SMRM procedure involved a 0.5 mm vertical incision in the anterior aspect of
the inferior turbinate; creation of a submucosal pocket on the medial surface of the bony
turbinate; debridement of the inferior aspect of the bony turbinate and some of the submucosal tissue with a straight microdebrider (4 mm tip, Tricut blade, 3000-cps oscillating mode)
in a ventrocaudal manner; and sponge nasal packing. The results of TCRFTVR and SMRM treatment were assessed 12 weeks and 6 months postoperatively with use of a visual analog scale,
tests of nasal epithelial function, and acoustic rhinometry.

There were no serious complications in either the TCRFTVR or SMRM sides and no significant
differences in complication rates between the two procedure types. Significant improvements
in obstructive symptoms and rhinometry variables had occurred in both treatment groups by
postoperative week 12 and were sustained at 6 months. No significant changes were observed
in saccharin transit time or ciliary beat frequency. Four of the TCRFTVR sides and two of the
SMRM sides required a revision operation (P not significant). There were no significant differences between TCRFTVR and SMRM in any outcome at either assessment time.
The authors comment that TCRFTVR and SMRM, two mucosa-sparing procedures, had identical results in their study. They also noted that the sides treated with SMRM did not have more
serious intraoperative or postoperative bleeding, although mucosal tears and synechia were
observed; that nasal packing is not required after TCRFTVR; that TCRFTVR may be more expensive because of the high cost of the disposable needle tip compared with the multiple-use
tips employed in SMRM; and that the possibly lower rate of revision operations required after
SMRM compared with TCRFTVR should be investigated in future studies with more patients
and a longer follow-up time. The authors conclude that TCRFTVR is more minimally invasive
than SMRM.
Kizilkaya Z, Ceylan K, Emir H, Yavanoglu A, Unlu I, Samin E, Akagn MC. Comparison of radiofrequency
tissue volume reduction and submucosal resection with microdebrider in inferior turbinate hypertrophy.
Otolaryngol Head Neck Surg 2008;138:176-81.

Effects of Microdebrider-Assisted Inferior Turbinoplasty on Nasal Resistance and


Quality of Life in Patients with Allergic Rhinitis
This prospective study compared the results of both objective and subjective assessments in
50 patients with perennial allergic rhinitis before and 1 year after inferior turbinoplasty using
a microdebrider with a small (2 mm) blade incorporated with an elevator (Medtronic ENT).
The objective evaluations were measurements of total nasal resistance at anterior rhinomanometry. The subjective analysis used the Rhinoconjunctivitis Quality of Life Questionnaire
(RQLQ), which addresses seven separate domain issues (e.g., sleep, nasal symptoms, and eye
symptoms), as well as overall condition. Preoperatively, all patients had substantial mucosal
hypertrophy of the inferior turbinates. Debridement of submucosal tissue from the inferior
turbinates was performed with the microdebrider blade positioned mediolaterally from the
submucosal plane and at a speed of up to 3000 rpm.
No patient had postoperative bleeding, crusting, synechia, foul odor, or atrophic changes.
Five had a mucosal tear but no loss of mucosa. One year after surgery, there were significant
improvements in nasal resistance (preoperative and postoperative values, 0.45 and 0.28 Pa/
cm3 per second, respectively; P < 0.001) and all separate domain and overall RQLQ scores (P <
0.005).
The authors note that the microdebrider technique achieved effects similar to those of submucosal turbinectomy: it relieved nasal obstruction, decreased the allergy-affected cells, and
destroyed the branch of the postnasal nerve, which contributes to sneezing and hypersecretion, thereby improving several nasal symptoms (obstruction, rhinorrhea, sneezing, and

postnasal drip). They also mention several other benefits of the procedure: it can be performed
on an outpatient basis with use of local anesthesia, the postprocedure duration of nasal
packing is shorter, and visualization with a 30-degree endoscope is improved. The authors
conclude that microdebrider-assisted inferior turbinoplasty offers effective volume reduction
with preservation of the physiologic function of the turbinates and it averts complications.
Huang T-W, Cheng P-W. Changes in nasal resistance and quality of life after endoscopic microdebriderassisted inferior turbinoplasty in patients with perennial allergic rhinitis. Arch Otolaryngol Head Neck Surg
2006;132:990-3.

Radiofrequency vs Microdebrider-Assisted Partial Turbinoplasty


This article describes a randomized, long-term study that compared outcomes achieved with
radiofrequency (RF; Somnus Medical Technology) with those obtained with a microdebrider
(Medtronic ENT) in partial turbinoplasty for the treatment of nasal obstruction due to inferior turbinate hypertrophy. Thirty patients underwent an RF procedure (group 1), and 30 had a
microdebrider-assisted operation (group 2). In group 1, a 1 mm-diameter RF needle electrode
was inserted submucosally at the anterior head of the inferior turbinate into the posterior
portion, and the turbinate was ablated by using a power level of 6 W. In group 2, redundant
and hypertrophied mucosa on the inferomedial side of the inferior turbinate and anterior
head region was trimmed with a microdebrider with a straight, 4 mm, aggressive-cut blade
employed at a speed of 2300 to 3000 rpm.
A visual analog scale was used to assess the patients perceptions of symptoms of nasal
obstruction preoperatively and 3, 6, and 12 months after surgery. Data on the patients satisfaction with their treatment were also obtained, as was information on preoperative and
postoperative postnasal drip. Operating time, duration of crust formation, and any postoperative bleeding episodes were recorded for each patient. Acoustic rhinometry was performed
preoperatively and 12 months after surgery.
In both groups, nasal obstruction was significantly improved compared with preoperative
levels at all postoperative assessment times. Twelve months after surgery, symptom improvement was significantly greater in patients in group 2 (the microdebrider group) compared
with those in group 1 (P > 0.05). Also at 12 months, group 2 patients had significantly better
acoustic rhinometry results, and more patients in that group than in group 1 were satisfied
with the results of their surgery. There was no significant difference between group 1 and 2
with respect to operating time, duration of crust formation, or postnasal drip. Group 2 had
significantly more cases of postoperative bleeding (eight cases vs two in group 1).
The authors note that the microdebrider is now regarded as an essential instrument in surgical
rhinology. It can be used either on the external turbinate surface (the method the authors
prefer) or within the turbinate, and it allows precise removal of soft tissue. The authors speculate that the inferior long-term results with RF may have been due to insufficient thermal
injury and fibrosis or shrinkage of turbinate mucosa and slight mucosal swelling after 6
months postoperatively. In contrast, say the authors, the microdebrider effectively and
precisely reduces the external surface of the hypertrophied inferomedial mucosa and the anterior head of the inferior turbinate, without increasing the time required for mucosal healing.

Although the number of postoperative bleeding episodes was higher in group 2, all were
easily controlled by temporary nasal packing. The authors conclude that they expect the use of
the microdebrider in turbinate surgery to increase and that the safety and effectiveness of the
microdebrider method will be confirmed by subsequent studies.
Lee JY, Lee JD. Comparative study on the long-term effectiveness between coblation- and microdebriderassisted partial turbinoplasty. Laryngoscope 2006;116:729-34.

Modified Endoscopic Turbinoplasty, Submucosal Powered Turbinoplasty, and


Submucosal Electrocautery: Randomized Trials
This article describes two prospective, randomized, controlled, double-blinded trials: one
comparing submucosal electrocautery (SEC) with submucosal powered turbinoplasty (SPT) and
one comparing SPT with modified endoscopic turbinoplasty (MET). All patients had symptomatic nasal obstruction (allergic or nonallergic) that was unresponsive to medical therapy. The
turbinate reduction method was determined randomly. Patients with odd numbers underwent
SPT on the left side and those with even numbers underwent SPT on the right side. The opposite
turbinate was treated with SEC or MET, depending on the trial. Patients subjective scores for nasal
obstruction and rhinorrhea were obtained 1, 4, and 12 months after surgery, as were results of clinical examinations, rhinometry, anterior rhinoscopy, and nasendoscopy conducted by examiners
blinded to the treatment method.
The MET procedures included creation of a window at the anterior aspect of the inferior
turbinate to access the lateral mucosa, rather than medial fracturing of the turbinate, which
can destabilize it and make the reduction procedure more difficult. A microdebrider blade
(Medtronic ENT) was used to remove mucosa on the lateral aspect of the inferior turbinate and
expose the turbinate bone. An elevator was employed to lift the medial mucosa away from the
bone in a subperiosteal plane, thereby allowing a sharp dissection and reduction of trauma to
the mucosa.
The only postoperative complications in the study were moderate bleeding (not requiring
packing), which occurred in none of the 50 patients who had SEC, 7 of the 100 patients who
had SPT, and 2 of the 50 patients who had MET; crusting, which occurred in 58% SEC, 2% SPT,
and no MET patients; and pain, which occurred in 22% SEC, 9% SPT, and 14% MET patients.
In the SEC vs SPT trial, both procedures initially improved subjective nasal obstruction symptoms
effectively in at least 92% of cases. Over time, however, regular use of decongestants increased
in both treatment groups, suggesting a deterioration in the benefit the therapy. The examiner
assessments revealed a significantly higher rate of improvement in nasal patency in the SPT
group. In the SPT vs MET trial, both procedures initially improved subjective nasal obstruction
symptoms effectively in at least 96% of cases. In the SPT group, however, regular use of decongestants increased from 1 to 12 months postoperatively. In the MET group compared with the
SPT group, significantly more patients had relief of nasal obstruction with only occasional or
no use of decongestants at the 4- and 12-month assessments. The rate of change between the
objective examiner scores comparing SPT to MET was not statistically significant. None of the
three procedures decreased rhinorrhea significantly.

The authors conclude that powered turbinoplasty provides an effective, reliable, long-term
improvement in nasal airway patency and relief of nasal obstruction, with minimal complications. They also comment that powered turbinoplasty is cost-effective and technically
straightforward.
Sacks R, Thornton MA, Boustred RN. Modified endoscopic turbinoplastylong-term results compared
to submucosal electrocautery and submucosal powered turbinoplasty. Presented at: American Rhinologic
Society Spring Meeting; May 13-16, 2005; Boca Raton, FL.

Inferior Turbinate Reduction with the Microdebrider


This article describes the microdebrider (Medtronic ENT) submucosal procedure for reducing
the nasal turbinates in children with sleep-disordered breathing (SDB) associated with turbinate
swelling refractory to medical treatment. The author notes that there are a variety of techniques for reducing turbinate size, but the ideal procedure spares the mucosal lining, thereby
promoting a quicker recovery and possibly decreasing the likelihood of excessive bleeding and
the development of atrophic rhinitis. For these reasons, the author terms the Medtronic ENT inferior turbinate blade to be an ideal instrument for performing the procedure.
Most turbinate reductions for SDB are done in conjunction with an adenotonsillectomy, which
is performed first. At the beginning of the reduction procedure, a nasal decongestant spray
is applied and the anterior aspect of the inferior turbinate is injected with lidocaine with
epinephrine. The blade of the microdebrider (which has an elongated flat surface on one side
that facilitates dissection) is positioned at the anterior-inferior edge of the inferior turbinate.
The blade is then bluntly inserted at a 45-degree angle until it touches the turbinate bone. The
microdebrider is set in oscillating mode at 1000 cycles per second, and the blade is pushed
posteriorly along the bone for about 2 cm; going further may violate the mucosal lining and
cause excessive bleeding. Once a pocket has been developed between the turbinate bone and
submucosal layer, the blade is rotated to face the mucosa lining and the submucosal layer is
resected. The author believes that the use of a lower cycle-per-second setting helps maintain
the integrity of the lining. Postoperatively, minor oozing may occur for a few hours or days.
The author states that the role of nasal obstruction in sleep-disordered breathing is often overlooked by clinicians, and concludes that turbinate reduction with the microdebrider is a simple
and safe technique.
Friedman NR. Inferior turbinate reduction: an application for the microdebrider. Oper Tech Otolaryngol
2005;16:232-4.

Intraturbinate Stroma Removal with the Microdebrider in Chronic


Hypertrophic Rhinitis
The author describes the microdebrider technique he uses for reduction of hypertrophic turbinates and briefly reviews his results in 63 patients. Under visualization through a rigid endoscope
or surgical microscope, an anesthetic and vasoconstricting agent is infiltrated into the head of
the inferior turbinate. An incision is made on the inferior and lateral border of the head, a plane
is created along the turbinate, and the microdebrider tip is inserted into it. The microdebrider
speed is set to 1800 rpm, with the suction indicator set to low. The tip is moved in a circular
motion to remove stroma. The entire procedure takes only a few minutes. Nasal packing material soaked in oxymetazoline is kept in place for a few hours postoperatively. If a very enlarged
6

turbinate tail is present, the reduction procedure can be performed in front of or over its body to
debride stroma from the site. In the authors series, no nasal bleeding occurred after the microdebrider procedure. Postoperative problems were minor and consisted of nasal congestion in 47
patients at 1 week after surgery, 18 patients at 2 weeks, and 3 patients at 1 month. Postoperative
burning or itching and rhinorrhea occurred in a maximum of two and four patients, respectively.
Pain was not reported by any patient. No problems were reported after 1 month. Among the 63
patients treated, 57 had improvements in subjective symptoms by 4 weeks after surgery, 61 by 2
months, 62 by 6 months, and all by 1 and 2 years. The author concludes that the microdebrider
method is safe and reliable. In addition, because it is a mucosa-sparing technique, mucociliary
flow patterns are not disturbed, so protection, filtration, and humidification processes continue
and iatrogenic atrophic rhinitis is unlikely to develop. In contrast, many common methods for
treating turbinate hypertrophy, including cauterization, diathermy, cryotherapy, total or partial
resection, and laser treatment, are destructive.
Yez C. New technique for turbinate reduction in chronic hypertrophic rhinitis: intraturbinate stroma
removal using the microdebrider. Oper Tech Otolaryngol Head Neck Surg 1998;9:135-7.

Powered Instrumentation for Submucous Resection of the Inferior Turbinates


The authors note that submucous resection of the inferior turbinates is a conventional technique
for decreasing turbinate size to alleviate airway obstruction. Several methods have been used
to reduce the turbinates, including turbinectomy, submucous turbinectomy, inferior turbinoplasty, cryotherapy, submucous electrosurgery, and carbon dioxide laser turbinoplasty. None
of these techniques is perfect, and each has been associated with complications such as excessive resection resulting in atrophic rhinitis, postoperative bleeding, and crusting. Most also
involve destruction of the mucosa, which affects nasal physiology, yet the main goal of inferior turbinate surgery should be preservation of mucosal surfaces while reducing submucosal
and bony tissue. In an effort to achieve this goal, the authors began to use powered microdebrider instrumentation. This article describes their results with this technique in a prospective
study enrolling 120 patients with symptoms and signs of nasal obstruction and stuffiness related
to enlarged turbinates. The microdebrider procedure begins with an incision in the anterior
aspect of the bony turbinate and the creation, by sharp dissection, of a submucosal pocket on its
medial surface. The microdebrider is inserted into this pocket. The bony turbinate and some of
the submucosal tissue are debrided with the device set in 3000-cps oscillating mode. Hemostasis
is achieved by using suction electrocautery under direct visualization. The incision is not closed.
The reduction in turbinate size is immediately apparent.
Preoperatively and 6 weeks postoperatively in this series, anterior rhinoscopy and nasal endoscopy were used to grade the size of the turbinates. Patients also completed questionnaires
about their nasal symptoms before and 6 weeks after surgery.
Postoperative bleeding necessitating a return to the operating room occurred in two patients
(1.6%) early in the series; subsequently, a modification in cautery technique was made and no
additional bleeding complications occurred. Mucosal tears were observed in 55% of patients,
but there was no loss of mucosa. Synechia developed in 5%. No patient had crusting, foul
odor, or nasolacrimal duct injury. The questionnaire data showed that the number of patients

with severe bilateral nasal obstruction or stuffiness decreased from 100 preoperatively to none
postoperatively. Ninety patients had no nasal obstruction or stuffiness after surgery. Reduction
of the inferior turbinates was observed in all patients.
The authors note that the microdebrider allows precise and incremental tissue removal,
thereby preventing many of the complications associated with inferior turbinate surgery.
They believe that the ability to debulk the turbinate while preserving the mucosa is the major
advantage of the powered procedure. The authors conclude that microdebrider submucous
resection of the inferior turbinates is a safe method for achieving turbinate size reduction in
patients with nasal obstruction due to inferior turbinate hypertrophy.
Friedman M, Tanyeri H, Lim J, Landsberg R, Caldarelli D. A safe, alternative technique for inferior
turbinate reduction. Laryngoscope 1999;109:1834-7.

Mucosal-Sparing Techniques for Office Treatment of Inferior Turbinate


Hypertrophy
Each of the three authors describes a different, innovative office procedure for inferior
turbinate hypertrophy. The authors note that there are many methods for reducing the inferior
turbinates. Most improve the nasal airway, but the structures that remain postoperatively may
be unable to regulate airflow adequately, and morbidity (bleeding, crusting, and pain) varies
considerably. The three new approaches described all have mucosal preservation as one of
their basic goals.
The first approach, radiofrequency volumetric tissue reduction, uses radiofrequency (RF)
heating to induce submucosal tissue destruction that results in a decrease in tissue volume.
The procedure employs an RF generator (Somnus Medical Technologies) connected to a
single-use delivery tip and handpiece. Under direct visualization, the RF electrode is placed in
the anterior inferior portion of the turbinate and RF energy is delivered at maximum settings
of 10 W, 75C, and 500 J for about 90 seconds. A topical vasoconstrictor is applied to minimize bleeding. The author has found this procedure to be quick and associated with high
patient satisfaction and tolerance. A 70% to 80% subjective improvement can be expected.
Disadvantages include the equipment cost and risk of mucosal ulceration and epistaxis. The
technique also has limitations with respect to precise control of the degree of tissue reduction
and obtaining access to the posterior aspect of the inferior turbinate.
The Coblation method (ArthroCare) uses RF energy between electrodes in a saline medium to
create a field of ionized sodium molecules capable of ablating tissue. The author uses the bipolar
wand to make four to six tunnels on each inferior turbinate. In each tunnel, the wand is advanced
along the underlying bone with the Coblation mode activated and then withdrawn slowly with
the cautery mode activated. Bleeding from the puncture sites is common, so topical oxymetazoline is applied. The author concludes that the Coblation procedure allows rapid, aggressive
reduction of the entire inferior turbinate, which retains its ability to function as a filter and
humidifier. Patients recover quickly, with minimal pain and nasal problems.
Microdebrider-assisted turbinate reduction involves excision of the erectile soft tissue of the
inferior turbinate with preservation of the overlying mucosa. A stab incision to the level of

the turbinate bone is made at the anterolateral surface of the inferior turbinate, and a supraperiosteal plane of elevation is developed. A suction elevator is inserted to clear blood from the
operative field. The active face of the microdebrider blade is positioned outward toward the
mucosal surface. Soft tissue is then resected under endoscopic visualization. Areas of dissection
and stroma removal should include the turbinate surface and the lateral wall, lateral and superior to the turbinate attachment. The author mentions several advantages of the microdebrider
approach. First, in contrast to thermoreductive techniques, it allows definitive, controlled volume
reduction. Second, the resection can be tailored to individual anatomical variations. Third, the
turbinate mucosa is preserved, allowing rapid healing and preservation of the humidification
and mucociliary transport properties of the turbinate. Finally, the approach can be done either in
the operating room as an adjunct to other procedures or in the clinic as the sole procedure. The
risk of postoperative bleeding after microdebrider treatment is higher than that after thermoablative procedures, but packing is effective in minimizing the risk. Also, care must be taken to
avoid perforating the mucosal turbinate flap during resection using the microdebrider.
Lee KC, Hwang PH, Kingdom TT. Surgical management of inferior turbinate hypertrophy in the office:
three mucosal sparing techniques. Oper Tech Otolaryngol Head Neck Surg 2001;12:107-111.

OTHER INFERIOR TURBINOPLASTY TECHNIQUES


Histopathological Changes after Inferior Turbinate Reduction Using Coblation Method
This article describes a study of the histopathological features of 22 soft-tissue samples
obtained from 16 patients in whom Coblation inferior turbinate reduction (CITR; performed
with a Coblator with a ReFlex Ultra 45 Wand, ArthroCare) failed to provide any or permanent relief from nasal obstruction. The samples were obtained during endoscopically guided
inferior turbinate mucotomy done with a microdebrider 4 to 33 months after CITR. Thirteen
of the 16 patients had experienced no symptom relief after CITR; in the other 3, symptoms
had recurred 6, 9, and 18 months, respectively, following the procedure. The samples from the
CITR-treated patients were compared with 18 archived hypertrophic IT specimens (controls)
from 14 patients who had undergone inferior turbinectomy alone.
All samples were assessed both qualitatively and quantitatively. The qualitative evaluation
investigated the type of epithelium, the presence of inflammation and fibrosis, and the population of submucosal glands and venous sinusoids. The quantitative analysis included standard
stereologic and morphometric assessments of the area fraction (relative proportion) of epithelium, connective tissue, glands, arteries, and venous sinusoids in the soft tissue. To determine
epithelial integrity, the researchers also measured the length of the basement membrane that
was covered with intact pseudostratified ciliated columnar epithelium, that was covered with
only a single layer of basal cells (indicative of partial epithelial shedding), and that was devoid
of epithelial cells.
The qualitative analysis showed that areas treated with CITR had marked fibrosis and depletion
of submucosal glands and venous sinusoids in the lamina propria. The quantitative evaluation
found that, compared with control samples, samples from CITR-treated patients had a significantly increased relative proportion of connective tissue and a significantly decreased relative
proportion of submucosal glands and venous sinusoids (P < 0.001 for all three comparisons).
The CITR samples also had a significantly decreased relative proportion of intact epithelium
9

(P = 0.03) and a significantly increased relative proportion of partial epithelial shedding


(P = 0.04). The authors comment that the partial epithelial shedding in the CITR samples probably resulted from a reduction in epithelial perfusion caused by vascular damage.
The authors note that although CITR uses far lower temperatures than laser techniques for
treating hypertrophied inferior turbinates, some of the histopathological changes in the
CITR samples they studied (ie, significantly increased connective tissue areas and significantly decreased areas of submucosal glands and venous sinusoids) were very much like
those observed after laser treatment. The authors conclude that the long-term implications of
these pathological changes on normal nasal physiologic features should be considered when
assessing whether to perform CITR.
Berger G, Ophir D, Pitaro K, Landsberg R. Histopathological changes after Coblation inferior turbinate
reduction. Arch Otolaryngol Head Neck Surg 2008;134:819-23.

Number of Treatment Sessions for Bipolar Radiofrequency Volumetric Inferior


Turbinate Reduction
The aim of this prospective study in 102 patients was to determine whether the number
of treatment sessions affects the longstanding results of submucosal bipolar radiofrequency volumetric tissue reduction (BRVTR; Coblator, ArthroCare) of the inferior turbinate.
Preoperatively, all patients had chronic hypertrophic rhinitis, hypertrophied inferior turbinates
(allergic or nonallergic), and nasal obstruction unresponsive to medical treatment. During the
procedure, the BRVTR unit was activated to a power between 5 and 6 (maximum power) and
three to four passes were done in each turbinate.
An immediate reduction in turbinate size was achieved during the BRVTR treatments, but this
was followed by rebound swelling and edema; thus, final results were not achieved for about
6 weeks. The maximum number of treatment sessions per patient during this time was five.
If complete symptom resolution did not occur after five treatment sessions, the patient was
excluded from the study. A year after the last treatment session in the patients remaining in
the study, a follow-up assessment using a visual analog scale (VAS) and acoustic rhinometry
was conducted.
Twelve of the 102 patients (12%) did not have complete relief from nasal obstruction after five
BRVTR treatment sessions. Of the remaining 90 patients (88%), 9 (10%) needed one session,
28 (31%) needed two, 29 (32%) needed three, 15 (17%) needed four, and 9 (10%) needed five
to obtain complete relief. In patients who had only one treatment session, a subjective sense
of nasal blockage and VAS values for nasal obstruction had increased significantly compared
with the 6-week findings by a year after treatment, whereas turbinate volume (TV) and nasal
fossa volume (NV) decreased significantly. In patients given two treatment sessions, satisfactory
results (by both objective and subjective criteria) were not maintained a year after the procedures. In patients who had three or four sessions, good results were maintained for the first year.
In patients given five sessions, the values for TV increased significantly after a year, whereas
changes in VAS and NV values were insignificant.

10

The authors note that the most important disadvantage of BRVTR turbinate reduction is that
the rate of improvement in nasal symptoms decreases over time, thereby requiring repetition of
treatment. The authors conclude that BRVTR treatment is effective and well tolerated but that
achievement of good longstanding results requires multiple treatment sessions.
Atef A, Mosleh M, El Bosraty H, El Fatah GA, Fathi A. Bipolar radiofrequency volumetric tissue reduction of
inferior turbinate: does the number of treatment sessions influence the final outcome? Am J Rhinol 2006;20:25-31.

Radiofrequency for Inferior Turbinate Hypertrophy and Use of a Preoperative Topical


Vasoconstrictor Drop Test
This prospective study in 22 patients had two objectives: (1) to assess results (up to 6
months) of radiofrequency volumetric tissue reduction (RFVTR) for treatment of inferior
turbinate hypertrophy refractory to medical therapy and (2) to ascertain whether improvements in symptoms after RFVTR correlated with the results of a topical vasoconstrictor drop
test (TVDT) administered preoperatively. The RFVTR treatment (15 W) was applied at each
of three different turbinate sites for 20 seconds (total, 60 seconds per turbinate). The TVDT
used 0.14 g of xylometazoline hydrochloride sprayed into the nasal airway. Nasal obstruction
was evaluated by using a visual analog scale (VAS, with 0 representing no obstruction and 10
representing complete and constant obstruction) preoperatively, after the preoperative TVDT,
and 1, 2, 4, 6, 8, 12, and 24 weeks after surgery.
Six patients required unilateral nasal packing after RFVTR. Fifteen of the 16 remaining patients
had some nasal discharge and hemorrhage for up to 7 days after surgery. Mild immediate
postoperative pain was also reported. Preoperative administration of the TVDT resulted in
a significant transient decrease in the mean VAS value (from 8 to 3). After RFVTR, VAS values
decreased significantly from the 2nd to the 12th postoperative week, and then increased to
about the preoperative post-TVDT level by the 24th week. The authors note that treatment
success was not apparent for the first weeks after therapy but that, from the 4th week on,
about half the patients had an apparent treatment success. They also conclude that their data
show that the results of RFVTR were clearly predicted by the TVDT. Therefore, say the authors,
the success of RFVTR does not correlate with the level of nasal obstruction noted by the
patient; rather, it correlates with the response of the patients turbinates to the TVDT.
Yilmaz M, Kemaloglu YK, Baysal E, Tutar H. Radiofrequency for inferior turbinate hypertrophy: could its longterm effect be predicted with a preoperative topical vasoconstrictor drop test? Am J Rhinol 2006;20:32-5.

Radiofrequency Treatment of Inferior Turbinate Hypertrophy: Long-Term Results


The goal of this study was to assess the long-term efficacy of radiofrequency volumetric
tissue reduction (RFVTR) in the treatment of inferior turbinate hypertrophy. The study initially
enrolled 32 patients: 16 who were randomly assigned to the RFVTR treatment group and 16
to the placebo group. Anesthesia, placement of the RFVTR probe, and sound from the RFVTR
generator were experienced by patients in both groups; however, active radiofrequency
energy was delivered only in the RFVTR treatment group. Patients remained in their assigned
groups for 8 weeks after the actual or placebo treatment. At the 8-week evaluation, those in
the placebo group were informed of their status and offered the option to cross over to RFVTR
treatment. Twelve elected this option; therefore, a total of 28 patients received RFVTR, but the
trial was not placebo-controlled after 8 weeks postoperatively.
11

The results of treatment were determined by use of a visual analog scale (VAS; with 0 representing no symptoms and 10 representing the worst symptoms imaginable) before treatment
and 8 weeks, 6 months, and 1 and 2 years afterward. The VAS assessed severity and frequency
of obstruction and overall ability to breathe. The data analysis compared pretreatment and
posttreatment scores from the 28 patients who received either initial or crossover RFVTR treatment. The authors do not report results in the initial placebo group (results earlier than 8
weeks after treatment).
Four patients who underwent RFVTR had mild to moderate pain requiring acetaminophen;
two others felt faint during the RFVTR procedure but were able to complete treatment. Only
19 of the 28 patients (68%) completed the entire 2 years of follow-up, which, the authors note,
may have introduced bias. All changes in VAS scores for all assessment times and symptoms
indicated significant improvement (P < 0.05) over pretreatment levels, although symptoms
were not eliminated. The mean VAS scores for frequency of nasal obstruction, severity of
obstruction, and overall ability to breathe were 4.1, 4.1, and 4.0, respectively, at 1 year posttreatment and 4.1, 4.9, and 4.2 at 2 years. Mean pretreatment VAS values for these symptoms
were 7.8, 7.7, and 7.5, respectively.
The authors conclude that their study indicates that RFVTR provides long-term symptom relief
similar to or better than that provided by other surgical treatments for inferior turbinate hypertrophy. They also mention the need for randomized controlled trials comparing RFVTR with
submucosal resection of the inferior turbinate, as well as the need for objective measures of
the results of treatment for inferior turbinate hypertrophy.
Porter MW, Hales NW, Nease CJ, Krempl GA. Long-term results of inferior turbinate hypertrophy with
radiofrequency treatment: a new standard of care? Laryngoscope 2006;116:554-7.

Radiofrequency Turbinoplasty vs Traditional Surgery


The prospective study described in this article included three groups of patients (25 in each
group) with manifestations of nasal obstruction associated with inferior turbinate hypertrophy refractory to medical therapy. Patients in group A underwent turbinoplasty using
classic surgical submucosal resection, group B patients had radiofrequency volumetric tissue
reduction (RFVTR), and group C patients (controls) were not treated. Nasal endoscopy, a visual
analog scale, anterior active positional rhinomanometry, and saccharin tests were used to
assess treatment outcomes 1 week and 1 and 3 months after surgery.
Turbinate edema and secretions decreased significantly compared with preoperative values in
patients in groups A and B beginning a month postoperatively, although there was a temporary increase in secretions in group A patients a week after surgery. Patients in groups A and B
had significant improvements in nasal obstruction and related symptoms at 1 and 3 months
after surgery, as well as a significant increase in nasal flow at 3 months. The nasal mucociliary
transport time increased in group A at 1 week, but the differences among the three groups
with respect to this measure was not significant at 1 month.
The authors say that both RFVTR and traditional turbinoplasty are effective but that RFVTR
offers several advantages: it requires only local anesthesia, nasal packing is not required, it

12

does not change mucociliary function or increase secretions and crusts, and patients can be
discharged immediately after treatment. The authors conclude, however, that because of the
short follow-up in their study, longer-term studies are needed to provide a more definitive
evaluation of the equivalency of RFVTR and traditional turbinoplasty.
Cavaliere M, Mottola G, Iemma M. Comparison of the effectiveness and safety of radiofrequency
turbinoplasty and traditional surgical technique in treatment of inferior turbinate hypertrophy.
Otolaryngol Head Neck Surg 2005;133:972-8.

Randomized, Long-Term Trial of Six Treatments for Inferior Turbinate Hypertrophy


In this 6-year study, 382 patients with nasal obstruction due to turbinate hypertrophy
unresponsive to medical therapy were randomly assigned to undergo one of six surgical
procedures to reduce the turbinates: turbinectomy, carbon dioxide laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateral displacement.
The submucosal resection technique in this paper appears to describe a manual version of the
powered removal of stromal tissue. Turbinectomy involved medial and upward fracture and
resection by angled scissors along the insertion close to the lateral nasal wall. Electrocautery
employed a high-frequency current delivered at a constant power to coagulate the medial
surface of the inferior turbinate. For cryotherapy, a standard nasal probe was applied along the
free edge and medial face of the inferior turbinate. In submucosal resection, an incision was
made on the head of the inferior turbinate, submucosal tissue was dissected from the medial
surface and inferior edge of the bone with an elevator, excess cavernous tissue was resected
with a Hartmann forceps, and the posterior end of the turbinate was resected. Submucosal
resection with lateral displacement included out-fracture and lateral displacement of bone.
Postoperatively, the turbinectomy, laser cautery, electrocautery, and cryotherapy groups had
chronic crusting in 34, 40, 39, and 40 cases, respectively, with synechiae developing more
frequently in the electrocautery group (21 cases). Bleeding occurred only in patients treated
with turbinectomy (25 cases), submucosal resection (10 cases), or submucosal resection with
displacement (8 cases). Patients underwent yearly postoperative examinations for up to 6
years. A significant initial postoperative improvement in nasal resistance values (on rhinomanometry and nasal volume assessments) occurred in all treatment groups (P < 0.001), but there
were significant differences among groups in improvement duration. Patients given turbinectomy or submucosal resection had normal, sustained nasal patency during follow-up. In
contrast, patients who underwent electrocautery or cryotherapy had a progressive, significant worsening of nasal resistance (P < 0.005) and nasal volume values (P < 0.001). After laser
treatment, nasal resistance improved and remained normal, but nasal volumes decreased
dramatically during the 6 follow-up years (P < 0.001). Only patients who had a submucosal
procedure achieved normal mucociliary transport times and secretary IgA concentrations (P <
0.001), with those who also underwent lateral displacement having the best results.
The authors note that the ideal surgical approach to inferior turbinate hypertrophy should be
limited to the erectile submucosal tissue and bony turbinate because the reduction in bone
size will create more respiratory space, the surgical maneuvers on the submucosal tissues will
create scars that can minimize submucosal engorgement in patients with allergic rhinitis, and
the preservation of the mucosa will minimize interference with physiologic functions. The

13

authors conclude that submucosal resection with lateral displacement comes closest to this ideal
and recommend it as the first-choice treatment for nasal obstruction due to inferior turbinate
hypertrophy.
Passli D, Passli FM, Damiani V, Passli GC, Bellussi L. Treatment of inferior turbinate hypertrophy: a
randomized clinical trial. Ann Otol Rhinol Laryngol 2003;112:683-8.

Coblation Inferior Turbinate Reduction


This prospective study investigated the safety and clinical effectiveness of the Coblation radiofrequency technique (ArthroCare) for inferior turbinate reduction in 26 adult patients with
soft-tissue inferior turbinate hypertrophy unresponsive to medical therapy. The patients
completed the Rhinosinusitis Symptom Inventory (RSI) and a short-form nasal questionnaire
before and 3 and 6 months after treatment. Two patients (8%) had marked epistaxis after the
procedure; one required nasal packing for 24 hours. At both the 3- and 6-month follow-up
assessments, there were significant improvements over preoperative RSI and nasal-questionnaire scores for nasal symptoms, systemic symptoms, overall sinonasal symptoms, degree
of nasal obstruction, and amount of time with nasal obstruction. There were no significant
improvements in mucus production, postnasal discharge, or snoring. The authors conclude
that the Coblation method is quick and yields good, persisting clinical results. Moreover,
as a submucosal technique, it preserves overall nasal physiologic features and is therefore
preferred to turbinectomy or surface methods. Coblation radiofrequency is not appropriate for
patients with primarily bony turbinate hypertrophy or extremely narrow piriform apertures.
The authors note that a disadvantage of the Coblation technique is that patients sometime
feel the thermal effect during deep or more posterior turbinate reductions.
Bhattacharyya N, Kepnes LJ. Clinical effectiveness of coblation inferior turbinate reduction. Otolaryngol
Head Neck Surg 2003;129:365-71.

Submucosal Diathermy for Chronic Nasal Obstruction Due to Turbinate Enlargement


This study was a retrospective review of the medical records of 91 patients who underwent
submucosal diathermy (SMD) for nasal obstruction due to inferior turbinate hypertrophy
that had been unresponsive to common medical treatments for at least a year. In all patients,
SMD was the only procedure used. Patients were questioned before the procedure about
nasal obstruction, chronic nasal discharge, snoring, headaches, and hyposmia or anosmia. An
anterior and posterior rhinoscopic assessment and an airflow measurement using a GertnerPodoshin nasal plate were performed preoperatively in each patient. The operation involved
insertion of a diathermy needle into the anterior end of the inferior turbinate, advancement of
the needle submucosally until the posterior end of the turbinate was reached, and withdrawal
of the needle over a 30-second period with the current applied. The patients were evaluated 2
months and 1 year postoperatively by means of a questionnaire about breathing through the
nose, rhinoscopic assessments, and airflow measurements using the nasal plate. There were
no complications from the SMD procedure. At the 2-month examination, 64 of the 91 patients
(70.3%) had subjective improvement in nasal breathing and 73 (80.2%) had good nasal
breathing on the nasal-plate assessment. During the first postoperative year, a second operation was performed in 16 patients because of unsatisfactory results from the initial procedure;
these patients were excluded from the second evaluation. At 1 year postoperatively, 65 of
the remaining 75 patients (86.7%) were symptom-free with respect to nasal breathing, and
14

67 (89.3%) had good nasal breathing on the nasal-plate assessment. The authors note that
SMD requires only local anesthesia, that it can performed in the office, and that it does not
require expensive equipment. The authors conclude that SMD is a safe and effective technique
for improving nasal breathing for both the short and long term in patients with chronically
obstructive inferior turbinates.
Fradis M, Malatskey S, Magamsa I, Golz A. Effect of submucosal diathermy in chronic nasal obstruction
due to turbinate enlargement. Am J Otolaryngol 2002;23:332-6.

Biopolar Radiofrequency Cold Ablation for Inferior Turbinate Hypertrophy


In this prospective study, the Coblation radiofrequency (ArthroCare) technique (set to a
power of 6 and used for 1 to 6 passes of 10 to 20 seconds each) was used to reduce the
inferior turbinates in 31 adult patients with symptomatic inferior turbinate hypertrophy unresponsive to medical management. In one patient, treatment was terminated prematurely
because of pain; another patient had epistaxis requiring overnight packing. Postoperative
pain was minimal; 12 patients said they had none. Most patients required minor debridement of crusting at the anterior turbinate head at their 2-week postoperative visit; no bleeding
occurred after this procedure and no patient had substantial granulation tissue. Six weeks and
3 months after surgery, scores on the Rhinosinusitis Symptom Inventory were significantly
lower than preoperative scores (P < 0.025) for all nasal symptoms except nasal congestion. One
patient had recurrence of nasal obstruction. The authors note that the Coblation technique
has the following advantages over electrocautery or monopolar radiofrequency reduction:
the immediate tissue reduction allows the surgeon to assess the degree of turbinate reduction
and further tailor the treatment approach; collateral tissue damage may be minimal, especially compared with that associated with conventional electrocautery; and the procedure is
rapid and well tolerated. The authors also comment that the Coblation technique has a definite learning curve and that, in their series, adjustment of anesthesia practices was required to
prevent pain during treatment. Moreover, some oozing from the turbinate entry point can be
expected, and this led to their case of epistaxis.
Bhattacharyya N, Kepnes LJ. Bipolar radiofrequency cold ablation turbinate reduction for obstructive
inferior turbinate hypertrophy. Oper Tech Otolaryngol Head Neck Surg 2002;13:170-4.

Radiofrequency for Turbinate Hypertrophy


In a prospective study in 14 patients with chronic nasal obstruction unresponsive to medical
treatment and no septic deformity, the authors used radiofrequency tissue reduction (S215
system; Somnus Medical Technologies) to treat inferior turbinate hypertrophy. Patients
were placed under local anesthesia, and three punctures were made in each turbinate. The
maximum values for temperature, power, local energy, and procedure duration were 85C, 8
W, 350 J, and 2.5 minutes, respectively. Three patients had pain during the procedure; in two,
treatment had to be stopped. None of the patients took any analgesic medication postoperatively. Patients were evaluated before and on days 3, 7, and 60 after the procedure. Compared
with preoperative findings, the abundance of secretions was increased significantly on day 3
and decreased significantly on day 60; turbinate edema was increased significantly on both
day 3 and day 60. Assessments using a visual analogue scale showed a significant decrease
in both daytime (P < 0.0005) and nighttime (P < 0.00001) nasal obstruction. Acoustic rhinometry showed a significant postoperative reduction in turbinate hypertrophy. Saccharine transit
15

times decreased significantly by day 60, whereas values for ciliary beat frequency were not
significantly different from those observed before surgery. The authors conclude that the
radiofrequency method is a useful alternative for reducing turbinate volume while preserving
the integrity and function of the surface epithelium. Patients should be informed preoperatively about the temporary nasal blockage, rhinorrhea, and inflammatory reaction that may
occur after the procedure.
Coste A, Yona L, Blumen M, Louis B, Zerah F, Rugina M, Peyngre R, Harf A, Escudier E. Radiofrequency
is a safe and effective treatment of turbinate hypertrophy. Laryngoscope 2001;111:894-9.

Radiofrequency Treatment of Turbinate Hypertrophy: Randomized Trial


This randomized, single-blinded clinical trial compared radiofrequency volumetric tissue
reduction (RFVTR) with a placebo procedure in the treatment of nasal obstruction in 32
patients with inferior turbinate hypertrophy. In patients assigned to the treatment arm, local
anesthetic agents were administered, the RFVTR probe was inserted into the anterior end of
the inferior turbinate until the active tip was submucosal, and delivery was accomplished with
the setting of a target temperature of 75, 15 W, and 500 J (Somnus Medical Technologies).
The patients in the placebo group underwent the same procedure, including application of
local anesthetics, but no energy was delivered. The sounds of the machine were preserved
to simulate treatment. The results of treatment were evaluated with use of a visual analogue
scale (VAS) completed by the patients before and 8 weeks and 6 months after the procedure.
Each patient also responded to a survey about complications, including pain and bleeding,
and underwent a nasal examination. Preoperatively, the treatment and placebo groups (n =
16 each) were comparable with respect to gender, race, age, allergy characteristics, and VAS
scores. There were no major complications during or after any procedure. Four patients (two
in each group) had mild to moderate pain during and shortly after the procedure; this was
relieved by acetaminophen. Follow-up examinations showed no evidence of crusting, ulceration, or surrounding mucosal damage. The inferior turbinates were appreciably smaller in
most patients given RFVTR. Analysis of the preprocedure and 8-week VAS scores showed that
both the treatment and placebo groups had significant postprocedure improvements in the
three outcome measures analyzed: frequency of obstruction, severity of obstruction, and
overall ability to breathe. However, the amount of improvement was significantly greater in
the treatment arm than in the placebo group with respect to severity of obstruction and ability
to breathe. Moreover, 100% of the patients in the treatment arm but only 44% in the placebo
arm had improvements in all three outcome measures. Six months after RFVTR, the mean VAS
scores for the treated patients assessed (including 12 from the placebo arm who chose to
undergo RFVTR after the 8-week evaluation) were significantly better than the pretreatment
VAS scores for all three outcome measures. The authors conclude that their study confirmed
that RFVTR is a safe procedure that is easily performed in an office setting and that produces
improvements in nasal obstruction significantly better than those provided by placebo.
Nease CJ, Krempl GA. Radiofrequency treatment of turbinate hypertrophy: a randomized, blinded,
placebo-controlled clinical trial. Otolaryngol Head Neck Surg 2004;130:291-9.

Radiofrequency Volumetric Tissue Reduction for Turbinate Hypertrophy


This prospective pilot study done at Stanford University evaluated the safety and effectiveness of radiofrequency volumetric tissue reduction (RFVTR) in the treatment of 22 patients
16

(43 turbinates) with nasal obstruction and associated turbinate hypertrophy refractory to
medical therapy. The study design limited application of RFVTR to the anterior third of the inferior turbinate. Preoperatively, all patients underwent anterior rhinoplasty with direct visual
inspection of the anterior nasal cavity and grading (on a 5-point scale) of the severity of nasal
obstruction at the anterior end of the inferior turbinate. Visual analogue scales (VASs) were
used to evaluate nasal breathing and snoring preoperatively and to assess nasal breathing,
snoring, pain, and patient satisfaction the day after treatment, 2 or 3 days after treatment, and
1, 4, and 8 weeks postoperatively. During the RFVTR procedure, a radiofrequency (RF) needle
electrode was inserted submucosally into the anterior head of the anterior turbinate under
direct vision. RF was delivered at 465 kHz for 60 to 90 seconds with a custom electrode, an
RF generator, and a computer-controlled algorithm (Somnus Medical Technologies). Topical
oxymetazoline was applied for hemostasis. Four patients (19%) had mild discomfort during
the treatment, and two had numbness of the teeth. No bleeding, crusting, dryness, or foul
odor occurred. Mild edema was observed on the first postoperative day and lasted up to 48
hours; it was not severe enough to block the airway but was correlated with a worsening of
nasal obstruction for up to 48 hours after surgery. Postoperative pain was nonexistent or mild
in 20 patients (91%); 3 patients required postoperative analgesia (acetaminophen). By 8 weeks
after treatment, subjective nasal breathing had improved in 21 of the 22 patients and patient
satisfaction with the therapy was high. There were also significant improvements in VAS scores
for the degree and frequency of nasal obstruction and in the extent of obstruction determined
by clinical examinations (P < 0.0001 for all differences between preoperative and postoperative findings). Snoring decreased in 12 of 13 patients and worsened in one. The authors note
that RFVTR is safer than submucous diathermy or electrocautery partly because the tissue
temperatures, power levels, and voltage required are much lower. They conclude that RFVTR
has minimal side effects and achieves subjective improvement in patients with symptoms
of nasal obstruction and that future investigations of this technique for managing turbinate
hypertrophy are warranted and needed.
Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Radiofrequency volumetric tissue reduction for
treatment of turbinate hypertrophy: a pilot study. Otolaryngol Head Neck Surg 1998;119:569-73.

Submucosal Bipolar Radiofrequency Ablation of Inferior Turbinates


The aim of this prospective, nonrandomized study was to assess the efficacy and morbidity
of bipolar radiofrequency thermal ablation (bRFTA; Coblation system; ArthroCare) of the
inferior turbinates in 20 adult patients with nasal obstruction caused by turbinate hypertrophy. The ablation therapy was delivered at 100 kHz with a voltage root-mean-square value
of 168 to 182. Preoperative and postoperative (1 week and 3, 6, and 12 months) nasal functions were evaluated with use of visual analogue scale (VAS) scores (for subjective results),
olfactory thresholds, saccharine transit time, rhinomanometry, and acoustic rhinometry. No
patient had mucosal edema, bleeding, or adherent crust formation after bRFTA treatment,
although pain and nasal discharge commonly occurred for the first 2 days postoperatively.
There were no adverse effects on nasal epithelial clearance time or olfactory functions. VAS
scores for nasal discharge, itching, sneezing, and crusting showed a significant decrease after
bRFTA (P < 0.001), whereas VAS scores pertaining to effectiveness (less frequent and less extensive nasal obstruction) and patient satisfaction increased significantly (P < 0.001). There were

17

no significant differences between preoperative and postoperative rhinomanometry or vasoconstrictive-effect results or between preoperative and long-term postoperative acoustic
rhinometry results. The authors conclude that bRFTA is a safe, minimally invasive procedure for
reducing turbinate volume without altering nasal mucosa or causing more than minimal pain.
They note that their results were comparable to those achieved with other surgical treatments
but that the ideal treatment for hypertrophied turbinates remains unclear. In contrast to
bRFTA, laser cautery, cryocautery, and electrocautery require general anesthesia and can cause
prolonged rhinorrhea, worsening of nasal obstruction due to edema, and crusting, all of which
probably result from the depth of tissue injury, which is unpredictable with these methods.
Bck LJJ, Hytnen ML, Malmberg HO, Ylikoski JS. Submucosal bipolar radiofrequency thermal ablation
of inferior turbinates: a long-term follow-up with subjective and objective assessment. Laryngoscope
2002;112:1805-12.

RELATED TOPICS
Subjective Assessment of Unilateral Nasal Obstruction
The purpose of this study was to identify the minimum difference in unilateral airflow that can
be reliably detected by a patient. The study enrolled 60 patients with a common cold (mean
duration, 2.5 days) and included 120 unilateral measurements of nasal obstruction obtained
by using posterior rhinomanometry to provide objective determinations of nasal flow and a
visual analog scale (VAS) for subjective assessments. The data analysis included calculation of
correlation coefficients.
Rhinomanometry showed that the range of total nasal flow in the study participants was 57
to 536 cm3 per second. On the VAS assessment, 77% of the participants correctly identified
the more obstructed nasal passage. Among participants with a difference in flow between
nasal passages of more than 100 cm3 per second (n = 22), 95% correctly identified the more
obstructed nasal passage. On the other hand, only 66% of those with a difference of less than
100 cm3 per second (n = 38) could identify the more obstructed passage (P = 0.009 for the
difference between the two participant groups). Moreover, as the difference in flow between
the nasal passages decreased from 100 cm3 per second, the percentage of patients able to
identify the more obstructed passage declined rapidly toward 50%, the proportion that would
be expected through chance alone.
The authors conclude that in patients with a difference between nasal-passage flow of more
100 cm3 per second, otorhinolaryngologists can be confident that the patients complaint of
unilateral nasal obstruction correlates with the actual side of obstruction. A lesser difference,
however, indicates that the perception of nasal obstruction may be caused by other factors
and that further investigation may be warranted to exclude other causes before a treatment
option is chosen.
Clarke JD, Hopkins ML, Eccles R. How good are patients at determining which side of the nose is more
obstructed? A study on the limits of discrimination of the subjective assessment of unilateral nasal
obstruction. Am J Rhinol 2006;20:20-4.

18

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