American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 668–672

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American Journal of Otolaryngology–Head and Neck

Medicine and Surgery
journal homepage: www.elsevier.com/locate/amjoto

Effects of surgical treatment of hypertrophic turbinates on the nasal

obstruction and the quality of life
Katharina Stölzel ⁎, Marie Bandelier, Agnieszka J. Szczepek, Heidi Olze, Steffen Dommerich
Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin, Campus Charité Mitte, Chariteplatz 1, 10117 Berlin, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Chronic hyperplasia of the inferior nasal concha is accompanied by a nasal obstruction; however, there is
Received 30 July 2017 no standardised surgical treatment for this condition. Here, we compared the outcome of three surgical tech-
niques frequently used to treat the hyperplasia of inferior turbinates: turbinectomy with lateralization, submu-
cosal electrocautery and laser cautery additional to septoplasty.
Materials and methods: One hundred and nine patients participated in this prospective randomized study upon
signing written consent. The subjects were randomly assigned to one of three intervention groups: 1) submuco-
sal turbinectomy with lateralization, 2) submucosal electrocautery or 3) laser cautery. All groups were followed-
up for up to 6 months after surgical intervention. During the four follow-up appointments, the outcomes were
measured with the modified German version of Sino-Nasal Outcome Test 20 questionnaire. In addition, the
nasal breathing and the absolute nasal flow rates and respective mucosal component were determined by the an-
terior rhinomanometry.
Results: Following surgery, the subjective and objective nasal obstruction decreased significantly in all three
groups. Moreover, the subjective symptoms measured by modified Sino-Nasal Outcome Test 20 improved signif-
icantly, although there were some temporal differences between groups regarding subjective nasal obstruction,
ear pressure, nasal discomfort, daytime fatigue, cough and dry mouth. The mucosal component of nasal conges-
tion decreased significantly after surgery.
Conclusions: All surgical techniques used to reduce the conchae mucosa led to a significant improvement in the
objective and subjective nasal breathing and the quality of life. Septoplastic reduction proved to be of additional
benefit.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction However, the abuse of α1-sympathomimetic drugs frequently leads to

The hyperplasia of the inferior nasal turbinate is frequently accom-
panied by chronic nasal obstruction. The hyperplasia may be caused
by an elevated number of blood vessels in the nasal mucosa and com-
mon venous sinusoids in the lamina propria of the inferior turbinates
[1]. A study of Talaat et al. has demonstrated that the reduction in the
number of blood vessels of inferior turbinates correlates with post-sur-
gical clinical improvement [2]. The hyperplasia of inferior turbinates
may be caused by chronic nasal infections [3], allergic and non-allergic
rhinitis, chronic hypertrophic rhinitis and compensatory hypertrophic
concha with septal deviation. The latter is caused by contact of nasal
septum with turbinates, which induces swelling of inferior turbinate
[4,5].
Primary therapy of patients with hyperplastic inferior nasal turbi-
nates includes conservative treatment with nasal sprays containing ei-
ther antihistamines, α1-sympathomimetic drugs or corticosteroids.
⁎ Corresponding author.
E-mail address: katharina.stoelzel@charite.de (K. Stölzel).
tachyphylaxis, leaving the attending physician with no choice but surgi-
cal reduction of inferior nasal concha [6]. The alternative approach (acu-
puncture) has proved ineffective for the treatment of hyperplastic
inferior nasal turbinate [7].
Conflicting studies claiming therapeutic success for one but not the
other surgical approach contributed to the present lack of consensus
lines of treatment for hyperplastic inferior turbinates with and without
septoplasty. Therefore, the first aim of our study was to compare the
surgical outcome by using subjective and objective parameters mea-
sured in patients treated with one of the three most common surgical
methods for turbinate reduction, namely the submucosal turbinectomy
with lateralization, submucosal electrocautery or laser cautery. The sec-
ond aim was to validate the benefit of consolidation of the two surgical
procedures: septoplasty and the reduction of hypertrophic inferior
nasal conchae. In order to better distinguish if the improvement of
nasal breathing is due to septoplasty or due to the reduction of hyper-
trophic lower nasal conchae, we determined the mucosal component.
In addition, anterior rhinomanometry was used to determine the differ-
ence in swelling of nasal mucosa before and after intervention.

http://dx.doi.org/10.1016/j.amjoto.2017.08.009
0196-0709/© 2017 Elsevier Inc. All rights reserved.
 K. Stölzel et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 668–672
To assess the subjective nasal obstruction, we also included parame-
ters such as pain or dryness of nose by using the modified questionnaire
“Sino-Nasal Outcome Test 20”, developed to evaluate symptoms of
chronic sinusitis [8].
2. Methods
This randomized, three-arm, prospective study was approved by a
local Ethics Committee (permit number EA1/188/13). One hundred
and nine patients were initially enrolled. The inclusion criteria included
age between 18 and 70 years, both genders and a positive diagnosis of
inferior nasal concha enlargement. The exclusion criteria included
chronic rhinosinusitis, nasal surgery prior to study, diabetes, nasal
polyps, autoimmune diseases and coagulation disorders. All patients
underwent surgical reduction of inferior nasal concha; the allocation
to given surgical technique group was randomized. Complete evalua-
tion over six months (four appointments) was possible for 75 subjects.
In that group, there were 23 women and 52 men. The subjects were on
average 36 years old (range 18 to 81 years).
All patients underwent surgical reduction of inferior nasal concha;
the allocation to given surgical technique group was randomized:
Group 1: lateralized submucosal turbinectomy, (19 patients)
Group 2: electrocautery (26 patients)
Group 3: laser cautery (30 patients)
The anterior rhinomanometry before and after the decongestion
with measurement of the difference as a mucous membrane compo-
nent was used as objective measurement parameters [9].
Subjects in all three study groups received self-report questionnaires
before and after the surgery. The questionnaire contained 18 items that
were based on the German versions of the Sino-Nasal Outcome Test 20
[10]. The modification was done by excluding questions that solely
regarded sinus symptoms (Table 1). Five answers weighted with points
were offered to meet the statistical requirements of a Likert scale. A
Likert scale contains several evaluative statements with which a patient
can agree with or reject them. The method was developed for measur-
ing personal attitudes. The unweighted values of the individual re-
sponses are added together to give the value of the scale. In the
present study, following answers were used: “strongly disagree” (0
points), “disagree” (1 point), “neither agree nor disagree” (2 points),
“agree” (3 points) and “strongly agree” (4 points).
The statistical analyzes were performed with the IBM SPSS Statistics
version 22 for Windows. For the statistical test procedures, a signifi-
cance level of 0.05 (Alpha = 5%) was used. For nominal features, the
chi-squared test was used and for metric features - the Kruskal-Wallis
test.
The treatment groups were also examined for possible differences
during the course of time. Since there had been an incomplete repeated
measures design (not all patients attended all three post-surgical ap-
pointments), the two-factorial experimental design with a between-
subjects factor and a within-subjects factor using the GEE (Generalized
Estimating Equations) methodology has been used.
Table 1
Questionnaire based on the German versions of the Sino-Nasal Outcome Test 20 German
Adapted Version (SNOT-20 GAV).
1. Need to blow out 10. Dizziness
2. Sneezing 11. Facial pain, pressure in the face
3. Runny nose 12. Problems falling asleep
4. Postnasal discharge 13. Nightly waking up
5. Thick nasal discharge 14 Daytime sleepiness
6. Cough 15. Reduced performance
7. Ear fullness 16. Concentration weakness
8. Ear pain 17. Frustration/restlessness/irritability
9. Smell reduction 18. Sadness
669
3. Results
The comparative statistical analyzes were carried out with data ob-
tained only from subjects who presented for follow-up, and included
75 patients assigned to one of the three intervention groups.
3.1. Changes in the objective nasal obstruction over time
There were no significant differences in the inspiration values (with-
out decongestant nasal spray) across the three groups prior to surgery,
and at 150 Pa, the values were on average 388.511 ml/s (SD = 38.925).
Following surgery, we observed a significant improvement of overall
inspiration without decongestant nasal spray in all three groups (p =
0.000) after one, three and six months. There were no significant differ-
ences between the groups.
The mucous membrane component was determined based on the
difference in total inspiration before and after administration of decon-
gestant nasal spray. Also here there was a significant improvement
6 months after surgery in each group (Fig. 1).
3.2. Changes in the subjective complaints over time
3.2.1. Changes in the subjective nasal obstruction over time
Seventy-six percent of patients reported a double-sided nasal ob-
struction prior to surgery. Half of the study participants' complained
about a permanent nasal obstruction, 31.3% of patients said to be partic-
ularly affected at night, and 17.9% stated difficulties with breathing
under special conditions such as physical exercises.
Following surgery, nasal obstruction improved significantly in all
three groups (p = 0.0001). Already during the first follow-up appoint-
ment, all patients reported decrease of nasal obstruction. Three months
after surgery, the grade of remaining nasal obstruction differed signifi-
cantly between the submucosal electrocautery group and the laser
group (p = 0.031), with the laser group having more reduced nasal ob-
struction. Six months after surgery, the differences between the groups
were no longer significant.
3.2.2. Significant subjective changes without significant differences between
surgery techniques
The symptoms that have not differed between the groups are listed
in Table 2. These symptoms include nightly waking up, problems falling
asleep, sneezing, ear pain and reduced concentration. All of them de-
creased significantly after surgical intervention (p = 0.001). The retro-
grade flow of secretion did not change significantly over time.
3.2.3. Subjective changes with significant differences between surgical
techniques
The symptoms listed in Table 3 also decreased following surgical in-
tervention. There were; however, significant differences between the
groups (Table 3).
3.2.4. Changes in the ear pressure
All patients reported a feeling of pressure in the ears prior to surgery.
Three months after surgery, there were significant differences between
the groups. Patients in the electrocautery group had significantly stron-
ger feeling of pressure in the ears than the patients in submucosal
turbinectomy group (p = 0.031). After 6 months, all patients reported
disappearance of the ear pressure (Table 3).
3.2.5. Change in cough over time
Prior to surgery, cough was not a serious complaint. One to two
months after the surgery, there was a significant group difference
between the submucosal turbinectomy group and laser cautery group
(p = 0.001), where patients from the laser cautery group did not suffer
from cough. During the follow-up appointments, patients from laser
cautery group retained the smallest symptom severity (Table 3).
670 K. Stölzel et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 668–672

Fig. 1. Mean mucous membrane component as difference of total inspiration in ml/s at 150 Pa before and after decongestion with a topical nasal decongestant xylometazoline over the
time.

3.2.6. Change in facial pain/pressure over time
In all three intervention groups, nasal discomfort was not reported
prior to surgery. Six months after the surgery, significant group differ-
ences were observed between the submucosal turbinectomy group
and electrocautery group (p = 0.024) and the electrocautery group
and laser cautery group (p = 0.011). Patients in the electrocautery
group were affected by nasal discomfort to the greatest degree (Table
3).
3.2.8. Changes in frustration, restlessness and irritation
Majority of patients reported being frustrated, restless and irritated
prior to surgery. During the second follow-up visit, a significant differ-
ence between electrocautery group and laser cautery group was ob-
served (p = 0.05) with the patients in the latter group reporting less
distress. After six months, there were no differences between the
groups and in all patients frustration, restlessness and irritation were re-
duced (Table 3).

3.2.7. Change of daytime sleepiness over time 4. Discussion

All patients reported fairly intense daytime sleepiness upon recruit-
ment. After the surgery, the mean value decreased in all groups mean-
ing that the daytime sleepiness occurred less frequently. One to two
months after the surgery, the daytime sleepiness was still reported by
the submucosal turbinectomy group still but in the other two interven-
tion groups it was barely a complaint. After half a year, significant differ-
ences between submucosal turbinectomy group and electrocautery
group (p = 0.041) and the submucosal turbinectomy group and laser
cautery group (p = 0.034) were noted again. Patients from electrocau-
tery group and laser cautery group stated that the daytime sleepiness
was no longer a problem. On average, the surgical intervention mini-
mized the daytime sleepiness in all groups (Table 3).
In the year 2014, the turbinate reduction was ranked 24th of the 50
most common surgeries performed in Germany and reached total of
151,225 cases [11]. Surgical techniques used to reduce the soft tissue
of turbinates are currently in review due to a lack of sustained improve-
ment of nasal obstruction and because of possible necrosis of mucosa,
crusting and bleeding [12,13]. Nevertheless, these techniques are wide-
ly used because of positive long-term effects and hardly any complica-
tions [14,15].
The two goals of our study were to compare the objective and sub-
jective outcomes between three surgical techniques used to treat hy-
perplasia of inferior turbinates and to determine their advantage in

Table 2
Significant changes in the overall averages of the item scores (p = 0.001) measured by the modified questionnaire Sino-Nasal Outcome Test 20 German Adapted Version (SNOT-20 GAV)
Likert scale 1–5.

Item Before surgery One month after surgery Three months after surgery Six months after surgery

Problems falling asleep 1,74 0,60 0,89 0,66

Nightly waking up 1,99 0,60 0,89 0,88
Sneezing 1,62 0,80 0,92 0,92
Postnasal discharge 1,62 0,80 0,92 0,92
Ear pain 0,55 0,34 0,22 0,27
Reduced concentration 1,53 1,08 0,78 0,82
 K. Stölzel et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 668–672 671

Table 3 radiofrequency therapy side were applied separately. After six months,
Subjective changes over time with significant differences between surgical techniques the best outcomes (indicated by anterior rhinomanometry, acoustic
(marked are significant differences p = 0.05); based on questionnaire Sino-Nasal Out-
come Test 20 German Adapted Version (SNOT-20 GAV), Likert scale 1–5.
rhinomanometry and by visual analog scale measuring nasal obstruc-
tion) were determined in a group of patients treated with the ultra-
Item Surgery Before One Three Six sound technique, followed by radiofrequency ablation. However, the
technique surgery month months months
results obtained in a group of patients treated with unilateral electro-
after after after
Surgery surgery Surgery cautery did not differ significantly [20].
In our study, in order to measure the rate of improvement, we deter-
Ear pressure Submucosal 0,63 0,79 0,17 0,58
turbinectomy mined the mucosal component, which is a novel outcome measure in the
Electrocautery 1,00 0,62 0,66 0,82 surgery of hypertrophic lower nasal conchae. The differences before and
Laser cautery 1,00 0,36 0,31 after swelling demonstrated significant decrease of the hypertrophy of
Cough Submucosal 1,21 1,16 1,10 0,90 the nasal mucosal membranes after the intervention. Our findings cor-
turbinectomy
Electrocautery 1,58 0,69 0,76 0,78
roborate the results of Devresen et al., Grymer et al. and Hilberg et al.
Laser cautery 1,13 0,38 0,47 0,52 [21–23]. We have not observed mucosal hypertrophy of the septum.
Facial Submucosal 0,93 0,53 0,13 0,16 Yu et al. showed that three months after the reduction of hypertrophic
pain/pressure turbinectomy lower nasal conchae with the Microdebrider with and without reduc-
Electrocautery 1,11 0,62 0,51 0,64
tion of the septum (n = 26 and 25, respectively), a significant improve-
Laser cautery 0,83 0,25 0,46 0,23
Daytime Submucosal 2,79 2,05 1,81 1,84 ment was noted in patients who underwent a reduction of septum [24].
sleepiness turbinectomy It is generally accepted that the surgical reduction of hypertrophic
Electrocautery 2,15 1,31 1,20 1,08 lower nasal conchae accompanied by nasal breathing problems is per-
Laser cautery 2,37 1,40 1,44 1.12 formed together with the septoplasty [22,25,26]. Scientific data regard-
Frustration, Submucosal 1,42 1,05 0,83 0,63
ing the improvement of nasal breathing by septoplasty with and
restlessness turbinectomy
and irritation Electrocautery 1,85 0,99 0,74 0,53 without additional reduction of the hypertrophic lower nasal conchae
Laser cautery 1,37 0,55 0,44 0,71 are scarce. The first study that included 80 patients using acoustic
rhinomanometry revealed that the nasal breathing improved after an
additional reduction of the hypertrophic lower nasal conchae [22].
After 5 years follow-up, no statistical differences were found between
the two groups with and without additional reduction of the hypertro-
phic inferior nasal conchae neither by using questionnaires (n = 50)
combination with septoplasty. For the comparison, we measured objec- nor by acoustic rhinomanometry (n = 37) [25]. Also Nunez et al. have
tive and subjective parameters in the patients treated. not found differences between the groups by means of anterior
According to Hofer et al., the mucosa-preserving reduction through rhinomanometry or questionnaire (n = 26 patients); however, the
the anterior turbinectomy should be the method of choice, since post- data were collected eight weeks after intervention [27]. Opposite results
surgical symptoms such as dry nose can be avoided [12]. Salzano et al. were delivered by Devseren et al. who demonstrated a significant im-
has also suggested partial inferior nasal turbinectomy to be the best provement six months after the surgery in a group of patients who
method, when compared to radiofrequency ablation, high-frequency underwent an additional reduction of the hypertrophic inferior nasal
ablation and electrocautery. Unfortunately, the authors followed up conchae. In that study, to measure the outcomes, the authors used ante-
their patients only for two months [16]. In our study, we were not rior and acoustic rhinomanometry and questionnaires [21].
able to reproduce the above observation. Possible reason for this dis- The questionnaires measuring various aspects of health, well-being
crepancy could be the difference in follow-up times (two months in as well as the health-related quality of life have become a popular out-
the Salzano study and three and six months in our study). come measurement in the field of otorhinolaryngology. We used such
Using all three surgical techniques: electrocautery, submucosal questionnaire to measure the subjective parameters and found that pa-
turbinectomy and laser cautery, we have observed sustainable improve- tients had the least subjective complaints when the laser cautery was
ment in the nasal breathing and a low complication rate, confirming used. The laser cautery is certainly the least invasive; however, the sus-
earlier results of Kizilkaya et al. and Prokopakis et al. [17,18]. Kizilkaya tainability of its results has often been put in question [28]. During the
et al. compared radiofrequency ablation with a submucosal reduction six months of follow-up period, we determined remission among the
by the microbrider, as both being purely soft tissue-reducing methods patients treated with laser cautery and the strongest positive effect indi-
(n = 30). Subjective (visual analog scale) and objective (acoustic cated by subjective nasal obstruction was found after 3 months after
rhinomanometry) measures have not detected the differences between surgery.
the groups 6 months after surgery. Prokopakis et al. included 2983 pa- All patients reported continuous improvement in the subjective
tients to compare three different types of the inferior turbinates surgery complaints after surgery. The group of patients who underwent electro-
(electrocautery, radiofrequency or CO2 Laser) and have demonstrated cautery, predominantly complained about the facial pain and pressure,
sustained significant improvement in the nasal breathing for up to one whereas the group which underwent the submucosal resection
year [18]. This also suggests that the purely soft-tissue-reducing complained significantly more about the daytime sleepiness than the
methods of turbinectomy are equally effective. other two groups.
In a prospective randomized long-term study including 382 patients,
Passalli et al. compared the submucosal resection with and without lat-
eralization, turbinectomy, submucosal electrocautery, laser cautery and 5. Conclusions
cryotherapy. The study was conducted over a period of 6 years, with ap-
proximately 63 participants per group. The best long-term outcome of Nasal mucosa-reducing techniques used for the inferior turbinate
the surgical procedure, as measured with acoustic and anterior surgery lead to significant improvement of objective and subjective out-
rhinomanometry, mucociliary transport and the secretion of IgA, were come measures. The technique of laser cautery induces the least post-
obtained by using submucosal resection with lateralization [19]. In an- surgical discomfort. However, none of the methods studied was signifi-
other study, Gindroz et al. have studied 60 patients with nasal obstruc- cantly superior to the others. In addition, we find that septoplasty signif-
tion of non-allergic origin. The ultrasound technology and the icantly contributes to the additional reduction of hypertrophic inferior
submucosal electrocautery or the ultrasound technology and turbinates.
672 K. Stölzel et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 38 (2017) 668–672
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