International Journal of Otorhinolaryngology and Head and Neck Surgery

Divya ML et al. Int J Otorhinolaryngol Head Neck Surg. 2021 Jun;7(6):1076-1082

http://www.ijorl.com

pISSN 2454-5929 | eISSN 2454-5937

Review Article

DOI: https://dx.doi.org/10.18203/issn.2454-5929.ijohns20212138

Surgical management for inferior turbinate hypertrophy: a narrative review

Mano Leoni Divya*, Valli Rajasekaran, D. Y. Raj Prakash

Department of Otorhinolaryngology, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth University, Kancheepuram, Tamil Nadu, India

Received: 26 January 2021

Revised: 23 March 2021

Accepted: 01 April 2021

*Correspondence:

Dr. Mano Leoni Divya,

E-mail: divyabasker@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Inferior turbinate hypertrophy can lead to bothersome symptoms of the nose. Inferior turbinate reduction has to be treated surgically for cases, which are refractory to medical treatment. Plethora of surgical techniques have evolved over the recent years to surgically treat inferior turbinate hypertrophy. Yet, there remains a lack of consensus on optimal surgical technique or a cumulative study on the merits and demerits of the surgical procedures performed. The aim of the study was to review 26 articles from time period of January 2000 to January 2021 studied on surgical techniques of turbinate reduction. On reviewing the studies, it was noted that conventional turbinectomy techniques were not preferred by surgeons to avoid chances of severe complications and hence more studies on newer advanced techniques were noted. Among the newer techniques to find an adequate balance between nasal physiology and tissue preservation RFTVR is preferred and is the optimal technique owing to its minimal invasion, performance ease and reduced complications. Most recent studies represent the benefits of RFTVR.

Keywords: Inferior turbinate hypertrophy, Turbinate reduction techniques, Turbinoplasty, Turbinectomy

INTRODUCTION

Treatment modality for inferior turbinate hypertrophy refractory to medical treatment is surgical reduction.1 Various surgical techniques for turbinate reduction have been studied. Optimal treatment technique includes resection of adequate tissue to reduce bulk of the turbinate and preserve viable mucosa to maintain nasal physiology.2 As newer surgical techniques are being explored for their efficacy. There is a lack of systemic comparative study of various turbinate reduction modality and their outcome. Objective of this study was to systematically evaluate the various surgical technique for treating inferior turbinate hypertrophy.

Articles were reviewed on surgical reduction of inferior turbinate hypertrophy and their outcomes were analyzed. This allowed us to study the most effective surgical technique for inferior turbinate hypertrophy.

METHODS

Search was undertaken using pubmed search engine to find various studies on surgical reduction of inferior turbinate hypertrophy from the months of January 2000 to January 2021. 26 articles relevant to our review as well as following our exclusion and inclusion criteria were included on surgical treatment of inferior turbinate hypertrophy comparing the effectiveness of surgical techniques; evaluating the treatment outcome of mentioned surgical techniques. Articles that had compared outcomes of techniques with other surgical procedures; were published in languages apart from English and single case report on specific intervention. Specific purpose of the study was to study the most appropriate surgical technique by comparing the treatment outcomes and occurrence of complication. Each technique with their merits and demerits were studied. Study year conducted, corresponding author, follow up period of the study, size of study and major findings were noted and studied.

Evaluation tools for subjective and objective symptoms pre and post operatively varied widely among most studies. It included NOSE scoring to visual analogue scale. Rhinomanommetric evidence for airway resistance in evaluating objective improvement were noted.

The PubMed research yielded 34 results. 26 articles were found to meet the inclusion criteria. Articles included the following surgical treatments of inferior turbinate hypertrophy: total turbinectomy, partial turbinectomy, sub mucosal resection, laser surgery, cryotherapy, electro cautery, radiofrequency ablation, and turbinate out fracture.

Table 1: Mentioned studies.
Table reproduced from source PDF page 2, part 1 of 3
Table reproduced from source PDF page 3, part 2 of 3
Table reproduced from source PDF page 4, part 3 of 3

DISCUSSION

Total turbinectomy

Total turbinectomy is the procedure of removal of complete turbinate tissue along with turbinate bone. Surgeons often avoid performing total turbinectomy in recent years attributing to the fear of complications due to removal of excess nasal mucosa. 2 out of 30 articles were identified that studied total turbinectomy. Siu et al on studying nasal aerodynamics following the surgical procedure found that nasal airway resistance was greatly reduced following total turbinectomy and this was due to a significantly less pressure gradient at the inferior turbinate head.11

This study brings out the significant benefit of total turbinectomy. Another study by Talmon et al found that the only major complication is bleeding and effective techniques to reduce bleeding can overcome this complication.28 Both the above studies, reflect total turbinectomy as an effective procedure with complications that can be managed with effective techniques.

Partial turbinectomy

Partial turbinectomy refers to selective trimming of the inferior turbinate. Partial turbinectomy removes an anterior portion of full-thickness tissue at the head of the inferior turbinate in the region of the internal nasal valve. 4 studies were identified that contribute to literature on partial turbinectomy. Mahajan et al found that partial turbinectomy is known to be effective in relieving nasal obstruction as well as optimal volume reduction with sustained preservation of function of inferior turbinate, 90% improvement in nasal obstruction and 83.3% improvement in size of turbinate turbinate was found.19

Marques et al in his comparative study found that turbinoplasty was as equally effective as turbinectomy.14 Kumar et al suggests that partial turbinectomy has significant improvement in nasal symptoms and aural symptoms in patients with allergic rhinitis.12

Roamano et al found that in partial inferior turbinectomy, crusting had been raised significantly within a period of 7 days post-procedure and further lessened considerably.20 The above studies suggest that partial turbinectomy aims at optimal tissue reduction to enable normal physiological functioning. Symptomatic relief following surgery is significant.

Turbinoplasty

Two main methods are known to fall under turbinoplasty, out fracture method as well as submucous resection method.

Turbinate outfracture

Turbinoplasty and outfracture are known to be effective volume reduction techniques. However, turbinoplasty causes higher reduction of the lower turbinate volume than outfracture.

Submucosal resection

An incision is to be made at inferior turbinate head. A micro debrider as well as blunt dissectors are further utilized so as to eliminate some of the hypertrophied turbinate tissue. Subsequently, the mucosa is redraped and allowed to heal over smaller turbinate bone. 3 articles from our review were studied on submucosal resection.

Lukka et al found submucosal resection to be cost saving compared to debrider, coblator, laser or techniques like radiofrequency assisted turbinectomy in their study, and none of their patients in Endoscopic submucosal resection (ESMR) group had significant intraoperative or postoperative bleeding.27 Recurrence of nasal obstruction due to inferior turbinate hypertrophy was not seen in patients who underwent ESMR. Ercan et al found significant turbinate volume reduction and improvement in nasal obstruction symptoms.5 Mahajan et al reported complications such as dryness of nose in 26.7%, adhesions in 3.3% and crusting in 17% of the patients.19

Microdebrider removal

One study of the selected articles found to study on microdebrider removal. Akugan et al found that the time of mucociliary transport was notably prolonged in the first postoperative week as well as first postoperative month in microdebrider turbinoplasty group.9 Intra-operative blood loss was minimal in the power microdebrider turbinoplasty.

Electrocautery

Uttarkar et al and Lukka et al studied electrocautery and found it to be effective in reducing nasal obstruction and turbinate size.22,27 Major complications encountered were post-operative pain. Post-operative pan was effectively managed by conservative treatment.

Laser cautery

Vijayakumar et al found that KTP laser used for turbinate reduction showed results in reducing symptoms of allergic rhinitis as well as can be performed as day care procedure, with minimal complications.21 Although nasal mucociliary clearance was found to be temporarily impaired in the first few weeks of postoperative period, it returned to normal thereafter. Olszewska et al found that by CO2 laser mucotomy nasal patency was improved after 3 months in 82% patients.8 Doreyawar et al found that diode laser being as good as any other laser for turbinate reduction is an effective choice for deserving cases.26 Although not as cost-effective as conventional methods, better quality of life with laser definitely makes it an important tool to replace the era of cold knife in turbinate surgeries in the modern day world.

Radiofrequency ablation

Casale et al, Dhulipalla et al, Assanasen et al and Kumar et al have studied on radiofrequency ablation.13,17,23,24 Conclusions indicate towards radio frequency ablation being the most ideal treatment option owing to its minimal invasion and its ease of performing the surgical procedure. It most effectively maintains normal nasal physiology without much damage to underlying mucosa or vessels and nerves.

CONCLUSION

Eight surgical techniques were compared which included both advanced and conventional surgical reduction of inferior turbinate hypertrophy. More studies are found on newer techniques such as radiofrequency ablation and fewer studies on techniques such as turbinoplasty and electro cautery.

Among conventional procedures, total inferior turbinectomy led to complication such as empty nose syndrome owing to disruption of normal nasal physiology. Even though it showed significant reduction in mucosal tissue and decreased airway resistance. Owing to fear of severe complications, total turbinectomy fails to be the optimal inferior turbinate reduction technique.

Partial turbinectomy and turbinoplasty in comparison with total turbinectomy have been noted to have fewer complications and hence a preferred choice among cost effective techniques. Turbinoplasty yields better outcomes in comparison to turbinectomy.

Among turbinoplasty types, submucosal resection is found to have better symptomatic outcome than out fracture technique even though out fracturing shows more reduction in turbinate volume. Advanced techniques such as microdebrider sub mucosal resection, laser, electro cautery as well as RFTVR. The technique of choice preferred by most studies as optimal is RFTVR. Complications such as intra operative bleeding seen in microdebrider or post-operative pain seen in electrocautery are not reported in studies of radiofrequency ablation.

As, conclusion surgically significant outcomes are best seen in turbinate reduction surgeries that are, minimally invasive, preserve adequate mucosal tissue, reduce airway resistance thereby relieving nasal symptoms and most importantly minimal complications. Most-newer and advance surgical techniques fit most of the above criteria. RFTVR emerges superior in terms of treatment and cost effectiveness.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

  1. 1. Dhulipalla S. Comparative study of response through reduction in the size of hypertrophied inferior turbinate causing nasal obstruction by different surgical modalities: a prospective study. Indian J Otolaryngol Head Neck Surg. 2015;67(1):56-9.
  2. 2. Oswal V, Krespi J, Kacker A. Nasal turbinate surgery. Principles and Practice of Lasers in Otorhinolaryngology and Head and Neck Surgery. USA: Kugler Publications; 2002: 221.
  3. 3. Bozan A, Eriş HN, Dizdar D, Gode S, Taşdelen B, Alpay HC. Effects of turbinoplasty versus outfracture and bipolar cautery on the compensatory inferior turbinate hypertrophy in septoplasty patients. Braz J Otorhinolaryngol. 2019;85(5):565-70.
  4. 4. Turk B, Korkut AY, Kaya KS, Salepçi E, Unsal O, Coşkun BU, et al. Results of Radiofrequency Ablation of Inferior Turbinate Hypertrophy in Patients with Allergic and Non-Allergic Rhinitis. Sisli Etfal Hastan Tip Bul. 2018;52(4):296-301.
  5. 5. Ercan C, Imre A, Pinar E, Erdogan N, Umut SE, Oncel S. Comparison of submucosal resection and radiofrequency turbinate volume reduction for inferior turbinate hypertrophy: evaluation by magnetic resonance imaging. Indian J Otolaryngol Head Neck Surg. 2014;66(3):281-6.
  6. 6. Deenadayal DS, Kumar MN, Sudhakshin P, Hameed S. Radiofrequency reduction of inferior turbinates in allergic and non-allergic rhinitis. Indian J Otolaryngol Head Neck Surg. 2014;66(1):231-6.
  7. 7. Corso E, Bastanza G, Donfrancesco V, Guidi ML, Morelli SG, Passali GC, et al. Radiofrequency volumetric inferior turbinate reduction: long-term clinical results. Acta Otorhinolaryngol Ital. 2016;36(3):199-205.
  8. 8. Olszewska E, Sieskiewicz A, Kasacka I, Rogowski M, Zukowska M, Soroczyńska J, et al. Cytology of nasal mucosa, olfactometry and rhinomanometry in patients after CO2 laser mucotomy in inferior turbinate hypertrophy. Folia Histochem Cytobiol. 2010;48(2):217-21.
  9. 9. Akagun F, İmamoglu M, Çobanoglu HB, Ural A. Comparison of Radiofrequency Thermal Ablation and Microdebrider-Assisted Turbinoplasty in Inferior Turbinate Hypertrophy: A Prospective, Randomized, and Clinical Study. Turk Arch Otorhinolaryngol. 2016;54(3):118-23.
  10. 10. El HDD, Ahmed MR, Madian YT. Comparison between power-assisted turbinoplasty and submucosal resection in the treatment of inferior turbinate hypertrophy. ORL J Otorhinolaryngol Relat Spec. 2011;73(3):151-5.
  11. 11. Siu J, Inthavong K, Shang Y, Vahaji S, Douglas RG. Aerodynamic impact of total inferior turbinectomy versus inferior turbinoplasty - a computational fluid dynamics study. Rhinology. 2020;58(4):349-59.
  12. 12. Kumar KMP, Karthikeyan P, Nirmal CV. Comparison of Endoscopic Turbinoplasty Versus Conventional Partial Inferior Turbinectomy in Chronic Hypertrophic Rhinitis. Indian J Otolaryngol Head Neck Surg. 2019;71(3):1895-99.
  13. 13. Casale M, Bottaro V, Sabatino L, Frari V, Bressi F, Vespasiani U, et al. The efficacy of radiofrequency volumetric tissue reduction of hypertrophied inferior turbinate in simple snoring. Eur Rev Med Pharmacol Sci. 2014;18(15):2160-8.
  14. 14. Rodrigues MM, Silveira DR, Francisco DOL, Dirce M, Marques O, Fernas M, et al. Comparison between turbinoplasty andendoscopic turbinectomy: Efficacy andclinical parameters. Int Arch Otorhinolaryngol. 2011;15(4):426-30.
  15. 15. Mehta N, Mehta S, Mehta N. Coblation-Assisted Turbinoplasty: A Comparative Analysis of Reflex Ultra and Turbinator Wand. Ear Nose Throat J. 2019;98(6):51-7.
  16. 16. Unsal O, Ozkahraman M, Ozkarafakili MA, Akpinar M, Korkut AY, Kurt DS, et al. Does the reduction of inferior turbinate affect lower airway functions?. Braz J Otorhinolaryngol. 2019;85(1):43-9.
  17. 17. Assanasen P, Choochurn P, Banhiran W, Bunnag C. Radiofrequency inferior turbinate reduction improves smell ability of patients with chronic rhinitis and inferior turbinate hypertrophy. Allergy Rhinol (Providence). 2014;5(1):12-6.
  18. 18. Parida PK, Surianarayanan G, Alexander A, Saxena SK, Santhosh K. Diode laser turbinate reduction in the treatment of symptomatic inferior turbinate hypertrophy. Indian J Otolaryngol Head Neck Surg. 2013;65(2):350-5.
  19. 19. Mahajan R, Nagaraj TM, Prashanth V. A Prospective Study to Compare the Efficacy of Powered Turbinectomy Versus Submucous Resection in the Surgical Management of Inferior Turbinate Hypertrophy. Indian J Otolaryngol Head Neck Surg. 2019;71(3):2203-9.
  20. 20. Romano A, Orabona GD, Salzano G, Abbate V, Iaconetta G, Califano L. Comparative study between partial inferior turbinotomy and microdebrider-assisted inferior turbinoplasty. J Craniofac Surg. 2015;26(3):235-8.
  21. 21. Vijayakumar S, Divakaran S, Parida PK, Gopalakrishnan S. Potassium titanyl phosphate laser turbinate reduction in the management of allergic inferior turbinate hypertrophy: Our experience. Allergy Rhinol (Providence). 2016;7(1):29-33.
  22. 22. Rao SUP, Basavaraj P, Yempalle SB, Ramachandra AD. A Prospective Study of Different Methods of Inferior Turbinate Reduction. J Clin Diagn Res. 2017;11(5):1-3.
  23. 23. 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):23-6.
  24. 24. Dhulipalla S. Comparative study of response through reduction in the size of hypertrophied inferior turbinate causing nasal obstruction by different surgical modalities: a prospective study. Indian J Otolaryngol Head Neck Surg. 2015;67(1):56-9.
  25. 25. Ravichandran SP, Ramasamy K, Parida PK, Alexander A, Ganesan S, Saxena SK. Comparison of efficacy of potassium titanyl phosphate laser & diode laser in the management of inferior turbinate hypertrophy: A randomized controlled trial. Indian J Med Res. 2020;151(6):578-84.
  26. 26. Doreyawar V, Gadag RP, Das M, Javali SB, Maradi N, Shetty D. Inferior Turbinate Reduction: Diode LASER or Conventional Partial Turbinectomy?. Ear Nose Throat J. 2019;7:95.
  27. 27. Lukka VK, Kurien R, Varghese L, Rupa V. Endoscopic Submucosal Resection Versus Endoscopic Submucosal Diathermy for Inferior Turbinate Hypertrophy. Indian J Otolaryngol Head Neck Surg. 2019;71(3):1885-94.
  28. 28. Talmon Y, Samet A, Gilbey P. Total inferior turbinectomy: operative results and technique. Ann Otol Rhinol Laryngol. 2000;109(12):1117-9.