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