Surgical Management of Turbinoplasty LO MEJOR DE LO MEJOR
Surgical Management of Turbinoplasty LO MEJOR DE LO MEJOR
Tu r b i n a t e H y p e r t ro p h y
Regan W. Bergmark, MD, Stacey T. Gray, MD*
KEYWORDS
Turbinate hypertrophy Turbinates Nasal obstruction Turbinate reduction
KEY POINTS
Inferior turbinate reduction can be accomplished through a variety of techniques, such as
submucosal resection, radiofrequency ablation, laser reduction surgery, and partial or
complete turbinectomy approaches.
Inferior turbinate reduction shows positive results in improving nasal obstruction symp-
toms postoperatively, but efficacy may decrease over time.
Bleeding and crusting are the most common complications of turbinate surgery.
Empty nose syndrome is a rare but morbid complication that is generally associated with
significant removal of the inferior turbinate.
High-quality clinical trials comparing techniques and assessing long-term outcomes are
largely lacking; more research is needed.
Turbinate surgery for nasal obstruction generally involves reducing the size of the
inferior turbinate. Turbinate surgery has been a common otolaryngologic proced-
ure since the late 1800s.1 Initially, total inferior turbinectomy was advocated.
This typically involved medializing the inferior turbinate and using a scissors or
blade to fully resect the turbinate. Due to complications, such as bleeding, signif-
icant crusting, and atrophic rhinitis, and concerns about nonphysiologic air turbu-
lence, total turbinectomy was largely abandoned. More recently, turbinate
reduction procedures have been advocated and a variety of surgical options
have been developed.1
Disclosure Statement: The authors did not receive financial support specifically for this project,
but all authors have academic research grant funding for their other work. Dr R.W. Bergmark
has research grant funding from the American Board of Medical Specialties Visiting Scholars
Program and the Gliklich Healthcare Innovation Scholars Program. Dr S.T. Gray has no
disclosures.
Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, 243
Charles Street, Boston, MA 02114, USA
* Corresponding author.
E-mail address: [email protected]
The inferior turbinate is composed of the bony turbinate, the submucosal tissue and
the overlying mucosa. Surgical procedures involve resecting, ablating or crushing
part, or all, of the turbinate to increase the size of the nasal airway. The appropriate
choice of procedure may depend on a patient’s anatomy and other concurrent pro-
cedures performed (such as septoplasty or septorhinoplasty) as well as the presence
or absence of other comorbidities such as allergic rhinitis. A clinical consensus state-
ment from the American Academy of Otolaryngology–Head and Neck Surgery on sep-
toplasty with or without inferior turbinate reduction states that (1) “inferior turbinate
hypertrophy can be an independent cause of nasal obstruction in the septoplasty pa-
tient” and (2) “inferior turbinoplasty is an effective adjunctive procedure to septoplasty
for patients with inferior turbinate hypertrophy.”2 In regard to patients with inferior
turbinate hypertrophy and allergic rhinitis, the American Academy of Otolaryngology
Head and Neck Surgery clinical practice guidelines on allergic rhinitis state that
“clinicians may offer inferior turbinate reduction in patients with [allergic rhinitis] with
nasal airway obstruction and enlarged inferior turbinates who have failed medical
management.”3
Efficacy is best evaluated through patient reported outcomes measures. The Nasal
Obstruction Symptom Evaluation instrument and visual analog scales are frequently
used. Quantitative measures of nasal airflow, resistance, or volume do not necessarily
correlate well with patient perception of effectiveness. Importantly, long-term fol-
low-up after turbinate surgery is needed to further quantify surgical effectiveness;
unfortunately, long-term outcomes are frequently lacking in the published literature
(see Emily Spataro and Sam P. Most’s article, “Measuring Nasal Obstruction
Outcomes,” in this issue, for more information on measurement of outcomes of turbi-
nate surgery and other nasal obstruction treatment).
Major complications of inferior turbinate surgery are rare. Failure of the procedure to
resolve nasal obstruction, either in the near term or long term, is the most common
issue. Bleeding and crusting are the most frequently described complications. These
complications have been reported more frequently with more aggressive techniques
that include greater resection of the turbinate or surgery in the more posterior aspect
of the turbinate, given the origin of the blood supply posteriorly. Bone necrosis, syn-
echiae, anosmia, and atrophic rhinitis have been described but are rare and generally
associated with more aggressive procedures.1 Empty nose syndrome is a rare compli-
cation associated with turbinate surgery and is discussed more thoroughly later.
Randomized clinical trials with robust study design are largely lacking for inferior turbi-
nate surgery despite the use of this technique for more than 120 years. Therefore, the
authors are largely unable to draw comparative conclusions about the benefits and
drawbacks of specific techniques and thus offer an overview of the different proced-
ures available with some common advantages and drawbacks for each technique. A
Cochrane review in 2010 did not find any studies that met inclusion criteria of random-
ized controlled trials comparing inferior turbinate surgical techniques or comparing
inferior turbinate surgery to medical management of turbinate hypertrophy.4 The
Surgical Management of Turbinate Hypertrophy 3
main problems with existing studies that did not meet Cochrane inclusion criteria
included lack of randomization, lack of long-term follow-up, lack of disease specificity
(ie, combining allergic and nonallergic rhinitis patients), combining adult and pediatric
patients, and small sample size.
From a value standpoint, there are insufficient published data on cost differences
between techniques to make a recommendation on the most financially respon-
sible approach. The equipment costs are different (ie, laser, microdébrider, simple
blade, and radiofrequency ablation device) and may depend on the use of those
tools by the surgeon and facility or hospital for other cases or within the same
case for other portions of the procedure. Laser inferior turbinate surgery, for
example, was written about extensively in the 1990s, with the purported benefits
that it could be performed in the office without general anesthesia. Costly laser
equipment, however, was needed.5 For inferior turbinate reduction with septo-
plasty, there is significant cost variability based on surgeon, facility, operative
time, equipment needs, and associated complications.6 Future studies examining
the costs of inferior turbinate reduction in isolation, and when bundled with
other procedures, would help determine value for this specific component of the
procedure.6
Partial turbinectomy has been described with multiple different techniques, such as
cold resection of part of the turbinate. Many techniques leave a portion of the ante-
rior head for nasal humidification and the posterior aspect to decrease the risk of
bleeding. Medial flap turbinoplasty has been described as a way to reduce the
turbinate size with preservation of mucosa. The medial mucosal flap is elevated
and left intact and the turbinate bone and lateral mucosa are resected. The
branches of the inferior turbinate artery must be cauterized during this procedure.
Good long-term results have been described with this technique although more
studies are needed.7
described in the literature. Laser turbinate reduction has been described with many
different techniques, such as contact, noncontact, or interstitial. Lasers have been
described in the operating room and in the outpatient clinic setting with topical
anesthesia.
Evidence Base
Laser turbinate reduction was popularized in the 1990s, with a proliferation of research
during that time, and less so in the past 10 years. One review stated that laser turbinate
reduction could be done in the outpatient setting under local anesthesia but was
generally less effective long term compared with submucosal resection, turbinoplasty
(partial reduction), or turbinectomy.10 Some investigators have described good long-
term results with relief of nasal obstruction in a majority of patients at 2 years to 5 years
postoperatively.11,12 Other investigators have likewise endorsed good effectiveness of
laser inferior turbinate reduction as long as the nasal obstruction is due to swollen soft
tissue of the interior turbinate.13 No high-quality studies demonstrate significant differ-
ences in techniques that would lead to a strong recommendation for a specific laser
type. In 1 comparison between laser types, there were no statistically significant dif-
ferences in outcomes, with approximately half of patients reporting subjective
improvement at 1 year.14 The varying lasers do have different tissue penetration
and field effects. For example, CO2 laser has a more narrow field effect with more tar-
geted effects but also a higher potential risk for bleeding complications than other la-
sers discussed in this article.15 One study showed that 84% of patients who
underwent diode laser inferior turbinate reduction surgery had improvement of symp-
toms at 1 year.16
Evidence Base
Inferior turbinate outfracture is commonly used during nasal surgeries with minimal
side effects but generally has not shown lasting duration of symptomatic improve-
ment. In many studies, it appears the turbinate either remedializes or continues to hy-
pertrophy such that benefit is lost. Therefore, turbinate outfracture is generally used in
combination with an additional technique to improve nasal airflow, such as turbinate
reduction or septoplasty.17
A recent study showed that after outfracture, the bony turbinate remains
lateralized at 6 months postoperatively, but that the overlying soft tissue hypertro-
phies in a compensatory fashion.18 CT scans were performed preoperatively
and 6 months postoperatively on patients. The distance to the inferior turbinate
bone from the median line increased, showing that the turbinate bone remained
lateralized; the width of the bone was also smaller.18 The soft tissue of the
inferior turbinate increased, however, between preoperative and postoperative
CT scans, demonstrating compensatory hypertrophy.18 The investigators
concluded that a volume reduction surgery should be performed in addition to
outfracture.18
Surgical Management of Turbinate Hypertrophy 5
Evidence Base
Studies generally demonstrate short-term improvement, with more limited studies on
long-term follow-up. A randomized clinical trial with 22 patients with a crossover design
demonstrated short-term superiority of bipolar radiofrequency ablation compared with
placebo 6 weeks to 8 weeks after intervention.19 A study of 40 patients undergoing
radiofrequency inferior turbinate reduction demonstrated improvement of symptoms
as well as odor thresholds at 2 years postoperatively.20 Improvement in patient-
reported outcome measures and objective measures of nasal airflow has also been
demonstrated 3 years from time of treatment.21 At 3 years, a majority of patients under-
going RFVTR showed some sustained reduction in symptoms, although patients with
allergic rhinitis had a greater likelihood of symptom relapse versus those without allergic
rhinitis.22 Ciliary function and mucociliary clearance are generally preserved long term
with this technique. For example, in 1 study, ciliary function returned to normal by
3 months after radiofrequency ablation, and no changes were noted in mucociliary
clearance in an even shorter time frame (1 month, 2 months, or 3 months).23
Other techniques for inferior turbinate reduction or resection have been described.
Coblation has been studied in short-term studies.28 Cryotherapy and ultrasound-
assisted reduction have also been described.17,29
TECHNIQUE COMPARISON
The anterior head of the inferior turbinate, which is believed to contribute most sub-
stantially to nasal obstruction symptoms, does not seem to drive otologic symptoms.
A recent randomized placebo (sham procedure)-controlled clinical trial of the effect of
turbinate surgery on eustachian tube dysfunction problems found no significant differ-
ences between groups.44 Patients undergoing turbinate surgery, as well as patients
undergoing a sham procedure, had significant improvements in the Eustachian
Tube Dysfunction Questionnaire scores. Patients in the intervention group underwent
microdébrider surgery, diode laser, or radiofrequency ablation of the anterior half of
the turbinate. Tympanometry was not different between groups at 3 months. There-
fore, the study did “not support the use of reduction of the anterior half of the inferior
turbinate as the sole procedure intended to treat ear symptoms.”44 More studies are
needed, particularly with attention to techniques addressing the posterior half of the
inferior turbinate.
Empty nose syndrome is a rare condition in which patients have substantial subjective
nasal obstruction despite significant space for airflow in the nasal cavity. Empty nose
syndrome almost exclusively seen in patients who have had turbinate surgery and is
classically described as a complication of complete resection of the inferior turbinates.
It is associated with reduced inferior turbinate volume, when comparing patients with
this condition to control patients (patients who had undergone pituitary adenoma
resection and did not have empty nose syndrome).45 It was the reason, however,
why less aggressive approaches to inferior turbinate resection became more popular.
A recent study on 6 patients with empty nose syndrome found that nasal airflow was
streamlined and jetlike in the middle meatus region, with limited airflow in the region of
the inferior turbinates.46 The authors also found evidence of potential sensory impair-
ment, with reduced trigeminal nerve function as evidenced by impaired lateral detec-
tion tests of menthol.46
SUMMARY
radiofrequency ablation, laser reduction, and limited resection are the most commonly
described techniques, without sufficient long-term data to make strong recommenda-
tions between them. Inferior turbinate outfracture alone seems ineffective. Total resec-
tion of the inferior turbinate should not be performed for nasal obstruction, based on a
small but real risk of empty nose syndrome. More long-term studies are needed to
determine long-term efficacy and to distinguish any clinically significant differences
in outcomes between techniques.
REFERENCES
1. Nurse LA, Duncavage JA. Surgery of the inferior and middle turbinates. Otolar-
yngol Clin North Am 2009;42(2):295–309, ix.
2. Han JK, Stringer SP, Rosenfeld RM, et al. Clinical consensus statement: septo-
plasty with or without inferior turbinate reduction. Otolaryngol Head Neck Surg
2015;153(5):708–20.
3. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis.
Otolaryngol Head Neck Surg 2015;152(1 Suppl):S1–43.
4. Jose J, Coatesworth AP. Inferior turbinate surgery for nasal obstruction in
allergic rhinitis after failed medical treatment. Cochrane Database Syst Rev
2010;(12):CD005235.
5. Englender M. Nasal laser mucotomy (L-mucotomy) of the interior turbinates.
J Laryngol Otol 1995;109(4):296–9.
6. Thomas A, Alt J, Gale C, et al. Surgeon and hospital cost variability for septoplasty
and inferior turbinate reduction. Int Forum Allergy Rhinol 2016;6(10):1069–74.
7. Barham HP, Knisely A, Harvey RJ, et al. How I do it: medial flap inferior turbino-
plasty. Am J Rhinol Allergy 2015;29(4):314–5.
8. Yanez C, Mora N. Inferior turbinate debriding technique: ten-year results. Otolar-
yngol Head Neck Surg 2008;138(2):170–5.
9. Passali D, Passali FM, Damiani V, et al. Treatment of inferior turbinate hypertro-
phy: a randomized clinical trial. Ann Otol Rhinol Laryngol 2003;112(8):683–8.
10. Janda P, Sroka R, Baumgartner R, et al. Laser treatment of hyperplastic inferior
nasal turbinates: a review. Lasers Surg Med 2001;28(5):404–13.
11. Katz S, Schmelzer B, Vidts G. Treatment of the obstructive nose by CO2-laser
reduction of the inferior turbinates: technique and results. Am J Rhinol 2000;
14(1):51–5.
12. Lagerholm S, Harsten G, Emgard P, et al. Laser-turbinectomy: long-term results.
J Laryngol Otol 1999;113(6):529–31.
13. Lippert BM, Werner JA. Long-term results after laser turbinectomy. Lasers Surg
Med 1998;22(2):126–34.
14. DeRowe A, Landsberg R, Leonov Y, et al. Subjective comparison of Nd:YAG,
diode, and CO2 lasers for endoscopically guided inferior turbinate reduction sur-
gery. Am J Rhinol 1998;12(3):209–12.
15. Janda P, Sroka R, Betz CS, et al. Comparison of laser induced effects on hyper-
plastic inferior nasal turbinates by means of scanning electron microscopy. La-
sers Surg Med 2002;30(1):31–9.
16. Cakli H, Cingi C, Guven E, et al. Diode laser treatment of hypertrophic inferior tur-
binates and evaluation of the results with acoustic rhinometry. Eur Arch Otorhino-
laryngol 2012;269(12):2511–7.
17. Sinno S, Mehta K, Lee ZH, et al. Inferior turbinate hypertrophy in rhinoplasty:
systematic review of surgical techniques. Plast Reconstr Surg 2016;138(3):
419e–29e.
Surgical Management of Turbinate Hypertrophy 9
18. Lee DC, Jin SG, Kim BY, et al. Does the effect of inferior turbinate outfracture
persist? Plast Reconstr Surg 2017;139(2):386e–91e.
19. Bran GM, Hunnebeck S, Herr RM, et al. Bipolar radiofrequency volumetric tissue
reduction of the inferior turbinates: evaluation of short-term efficacy in a prospec-
tive, randomized, single-blinded, placebo-controlled crossover trial. Eur Arch
Otorhinolaryngol 2013;270(2):595–601.
20. Garzaro M, Pezzoli M, Landolfo V, et al. Radiofrequency inferior turbinate reduc-
tion: long-term olfactory and functional outcomes. Otolaryngol Head Neck Surg
2012;146(1):146–50.
21. Assanasen P, Banhiran W, Tantilipikorn P, et al. Combined radiofrequency volu-
metric tissue reduction and lateral outfracture of hypertrophic inferior turbinate
in the treatment of chronic rhinitis: short-term and long-term outcome. Int Forum
Allergy Rhinol 2014;4(4):339–44.
22. De Corso E, Bastanza G, Di Donfrancesco V, et al. Radiofrequency volumetric
inferior turbinate reduction: long-term clinical results. Acta Otorhinolaryngol Ital
2016;36(3):199–205.
23. Rosato C, Pagliuca G, Martellucci S, et al. Effect of radiofrequency thermal abla-
tion treatment on nasal ciliary motility: a study with phase-contrast microscopy.
Otolaryngol Head Neck Surg 2016;154(4):754–8.
24. Kocak HE, Altas B, Aydin S, et al. Assessment of inferior turbinate radiofrequency
treatment: Monopolar versus bipolar. Otolaryngol Pol 2016;70(4):22–8.
25. Banhiran W, Assanasen P, Tantilipikorn P, et al. A randomized study of
temperature-controlled versus bipolar radiofrequency for inferior turbinate reduc-
tion. Eur Arch Otorhinolaryngol 2015;272(10):2877–84.
26. Di Rienzo Businco L, Di Rienzo Businco A, Ventura L, et al. Turbinoplasty with
quantic molecular resonance in the treatment of persistent moderate-severe
allergic rhinitis: Comparative analysis of efficacy. Am J Rhinol Allergy 2014;
28(2):164–8.
27. Kumar S, Anand TS, Pal I. Radiofrequency turbinate volume reduction vs.
radiofrequency-assisted turbinectomy for nasal obstruction caused by inferior
turbinate hypertrophy. Ear Nose Throat J 2017;96(2):e23–6.
28. Larrabee YC, Kacker A. Which inferior turbinate reduction technique best de-
creases nasal obstruction? Laryngoscope 2014;124(4):814–5.
29. Bhattacharyya N, Kepnes LJ. Clinical effectiveness of coblation inferior turbinate
reduction. Otolaryngol Head Neck Surg 2003;129(4):365–71.
30. Nease CJ, Krempl GA. Radiofrequency treatment of turbinate hypertrophy: a ran-
domized, blinded, placebo-controlled clinical trial. Otolaryngol Head Neck Surg
2004;130(3):291–9.
31. Gindros G, Kantas I, Balatsouras DG, et al. Comparison of ultrasound turbi-
nate reduction, radiofrequency tissue ablation and submucosal cauterization
in inferior turbinate hypertrophy. Eur Arch Otorhinolaryngol 2010;267(11):
1727–33.
32. Cingi C, Ure B, Cakli H, et al. Microdebrider-assisted versus radiofrequency-
assisted inferior turbinoplasty: a prospective study with objective and subjective
outcome measures. Acta Otorhinolaryngol Ital 2010;30(3):138–43.
33. Liu CM, Tan CD, Lee FP, et al. Microdebrider-assisted versus radiofrequency-
assisted inferior turbinoplasty. Laryngoscope 2009;119(2):414–8.
34. Brunworth J, Holmes J, Sindwani R. Inferior turbinate hypertrophy: review and
graduated approach to surgical management. Am J Rhinol Allergy 2013;27(5):
411–5.
10 Bergmark & Gray