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Original Paper

ORL 2011;73:151–155 DOI: 10.1159/000327607

Comparison between Power-Assisted Turbinoplasty and Submucosal Resection in the Treatment of Inferior Turbinate Hypertrophy

Diaa El Din Mohamed El Henawi Mohamed Rifaat Ahmed Yasser Taha Madian 

Faculty of Medicine, Suez Canal University, Ismailia , Egypt

Introduction

Inferior turbinate hypertrophy is one of the main causes of nasal obstruction [1] , and patients can benefit from turbinate reduction surgery when medical treat-ment fails [2] .

Several different methods have been proposed for the treatment of inferior turbinate hypertrophy, including partial and total turbinectomy, submucosal turbinecto-my, submucosal diathermy, cryotherapy and laser turbi-noplasty [3–7] . However, the main disadvantages of these techniques are the loss of mucosa and interference with mucociliary function [8] .

The main goal of turbinate surgery is to relieve the pa-tient’s symptoms and preserve the mucosal surfaces. Cur-rently, submucosal resection (SMR) turbinoplasty comes closest to meeting these targets [9, 10] .

When treating inferior turbinate hypertrophy, pow-er-microdebrider-assisted turbinoplasty (PAT) offers preservation of both the mucosa and the anatomy/phys-iology of the turbinate, which in turn leads to a very short postoperative period and reduced crust formation [11–13] .

This study aimed to compare the results of PAT and SMR in the treatment of inferior turbinate hypertrophy.

Key Words

Hypertrophy � Surgery � Turbinoplasty, power-assisted � Turbinate

Abstract

Objectives: To compare the efficacy of power-microdebrid-er-assisted inferior turbinoplasty (PAT) with submucosal re-section (SMR) in the treatment of inferior turbinate hypertro-phy. Methods: A prospective randomized clinical trial study of 46 patients with bilateral inferior turbinate hypertrophy. Patients were randomly divided into 2 groups: PAT and SMR. Results: Intraoperative blood loss was 37.1 8 7.4 ml in the PAT group and 47.8 8 9.5 ml in the SMR group (means 8 SD), while the operative times were 11.1 8 1.7 and 29.4 8 4.7 min, respectively. There was statistically significant lower blood loss in the PAT group, due to the shorter operating time. Con-

clusion: PAT is equally as safe and effective as SMR. It has a shorter operation time and reduced intraoperative blood loss. Copyright © 2011 S. Karger AG, Basel

Received: December 18, 2010 Accepted after revision: March 21, 2011 Published online: April 21, 2011

Mohamed Rifaat Ahmed, MD Faculty of Medicine, Suez Canal University Ismailia (Egypt) Tel. +20 185 043 825E-Mail m_rifaat   @   hotmail.com

© 2011 S. Karger AG, Basel0301–1569/11/0733–0151$38.00/0

Accessible online at:www.karger.com/orl

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Methods

A prospective randomized clinical trial study was conducted in the Otolaryngology Department, Suez Canal University Hos-pital, Ismailia, Egypt. Forty-six patients with bilateral inferior turbinate hypertrophy, for whom medical treatment had failed for at least 2 months, were divided randomly into 2 groups: PAT and SMR. Cases with a deviated nasal septum, nasal polyposis, nasal valve collapse, chronic sinusitis, nasal granulomas and previous nasal surgery were excluded.

All patients used a visual analogue scale to assess nasal ob-struction, postnasal discharge, allergic symptoms, hyposmia, headache and snoring (0 = no symptoms; 10 = severe and constant symptoms).

Nasal examinations (including anterior rhinoscopy, Cottle’s test and nasal endoscopy) were performed to assess the size of the inferior turbinate before and after the operation.

We evaluated the turbinate size according to Yañez and Mora [12] . To measure the width, the inferior turbinate must be: (1) ful-ly retracted; (2) engorged halfway to the nasal fossa; (3) engorged and reaching the nasal septum. To measure the length: (A) the inferior turbinate is not crossing the choanal arc line posteriorly, (B) reaching but not crossing the choanal arc line, (C) crossing the choanal arc line posteriorly.

Acoustic rhinometry was used to measure the minimal cross-sectional area (mMCA), the distance to the mMCA (dMCA) and the total nasal cavity volume (tNCV) from the nostril to 5 cm in-side the nasal cavity.

PAT cases underwent nasal packing with oxymetazoline (1%) for 10 min preoperatively, and injection with 3 ml lidocaine (1%) with 1: 100,000 epinephrine. A vertical incision was made in the anterior aspect of the inferior turbinate, followed by utilization of the Hall Linvatec straight microdebrider blade (4.2 ml), applied through the incision while rotating the microdebrider’s tip con-tinuously through a 360-degree angle until the required size re-duction of the inferior turbinate was obtained. Finally, anterior

nasal packing was placed for 48 h, while the patient received sys-temic antibiotics [14] ( fig. 1 ).

SMR cases were subjected to the same preoperative prepara-tion as the PAT group. A mucosal incision was made in the ante-rior part of the inferior turbinate. The submucosal tissues were dissected from the medial surface, the inferior edge of the bone and the anterior part of the bone; these tissues were removed us-ing biting forceps. Finally, anterior nasal packing was placed for 48 h, simultaneous with systemic antibiotic treatment [15] ( fig. 2 ).

Patients in both groups were re-evaluated 6 months after the operation.

Nasal crusts were classified according to Joniau et al. [16] (0 = no crusts; 1 = a few isolated crusts; 2 = less than 50% of the infe-rior turbinate is crusted; 3 = more than 50% of the inferior turbi-nate is crusted).

Results

The mean ages of the PAT and SMR groups were 25.1 and 26.2 years, respectively. Males made up 61 and 52% and females 39 and 48%, respectively. Nonsmokers formed 78.3% of both groups.

Bilateral nasal obstruction was noted in 82.6 and 78.3% of PAT and SMR groups, respectively, while a cyclic obstruction was detected in 17.4 and 21.7%, respectively. The mean degree of nasal obstruction was estimated as 8.2 in PAT group and 8.4 in SMR group according to the visual analogue scale.

Nasal discharges were recorded in 60.9% of the PAT group and 56.5% of the SMR group. Allergic symptoms were noted in 34.8% (PAT) and 21.7% (SMR); hyposmia

Fig. 1. Intraoperative turbinoplasty using the shaver blade. Fig. 2. Intraoperative SMR of the inferior turbinate.

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ORL 2011;73:151–155 153

in 13% (PAT) and 4.3% (SMR); headache in 21.7% (both groups); and snoring in 4.3% (PAT) and 8.7% (SMR).

Nasal endoscopic findings revealed type 3C turbinates in 52.2 and 56.5%, 3B in 30.4 and 34.8%, and 2B in 17.4 and 8.4% in PTA and SMR groups, respectively [12] .

Preoperative acoustic rhinometry parameters were (means 8 SD): mMCA (both groups) = 0.5 8 0.1 cm 2 ; tNCV = 8.2 8 0.9 cm 3 (PAT) and 8.3 8 1.3 cm 3 (SMR); mDMCA = 3.5 8 0.3 cm (PAT) and 3.4 8 0.3 cm (SMR). There were no statistically significant differences.

Intraoperative blood losses were 37.1 8 7.4 ml (PAT) and 47.8 8 9.5 ml (SMR). Operative times of 11.1 8 1.7 min (PAT) and 29.4 8 4.7 min (SMR) were reported, with statistically significant lower blood loss and a shorter mean operative time in the PAT group ( table 1 ).

Immediate postoperative pain scores were 2.4 8 2.1 and 3.3 8 2.3 in the PAT and SMR groups, respectively ( table 1 ).

One week postoperatively, no crust was found in 82.6% of the PAT group and 69.6% of the SMR group (no statis-tical difference); the remaining patients showed a few iso-lated crusts.

While cases in both groups were still suffering from nasal obstruction 4 weeks postoperatively (n = 2; 8.7%), significant improvements occurred in 91.3% (no statisti-cally significant difference) ( fig.  3–5 ). After 6 months, 4.3% of cases (n = 1) in both groups were still suffering

Table 1. Operative characteristics of both groups

PAT(n = 23)

SMR(n = 23)

pvalue

Amount of blood loss, ml 37.187.4 47.889.5 0.001*Operative time, min 11.181.7 29.484.7 0.001*Immediate postoperative pain 2.482.1 3.382.3 0.2

* p < 0.05.

Fig. 3. Inferior turbinate after PAT. Fig. 4. Inferior turbinate 1 week after PAT.

Fig. 5. Inferior turbinate 1 week after SMR.

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from nasal obstruction, again with no between-group difference.

In addition, turbinate type 1A was found in 95.7 and 91.3% of PAT and SMR groups, respectively (no sig. dif-ference); score 1B was found in the remainder.

mMCA measurements were 1.3 8 0.07 and 1.3 8 0.08 cm 2 in PAT and SMR groups, respectively; tNCV were 13.3 8 1.1 and 13.2 8 0.8 cm 3 , respectively; mDMCA were 1.7 8 0.3 and 1.6 8 0.2 cm, respectively. There were no statistically significant differences.

Discussion

Surgical reduction of the turbinate is the treatment of choice when a patient is unresponsive to medication [17] . However, techniques which destroy the turbinate mucosa are more likely to lead to loss of turbinate function along with crust formation and adhesions [18] . On the other hand, submucosal cauterization, which preserves turbi-nate function, has some limited short-term disadvantag-es [10] .

PAT has the advantages of mucosal preservation alongside controlled volume reduction, minimal trauma, reduced bleeding and enhanced precision – providing marked improvements in nasal obstruction [13] .

In this study, postoperative assessment of nasal ob-struction after 1 month revealed a statistically significant improvement in most patients of each group. Further im-provement occurred after 6 months, again without any statistically significant differences between the groups.

Our findings are consistent with the study of Chen et al. [2] , who compared endoscopic submucosal tissue re-section with resection with microdebrider. They found no significant differences between improvements in na-sal obstruction at 1 year, which continued to be the case 3 years later.

In addition, Benchev [13] – who used bilateral turbino-plasty with microdebriders – reported that an improve-ment of over 50% in nasal obstruction between pre- and postoperative values was found in 79% of patients.

In our study, preoperative nasal endoscopic assess-ment of the turbinate size showed that most of the pa-tients had huge inferior turbinate engorgement (scored as 3C and 3B). One month after the operation, most of patients were scored as 1A or 1B. By 6 months, further improvements had occurred. These results are consistent with Yañez and Mora [12] . Their endoscopic evaluation of 341 patients presenting with type 3C showed that 6 months later turbinate engorgement had significantly

decreased in most of the patients (92.6% now had size 1A).

Acoustic rhinometry assessment after 1 and 6 months revealed that mMCA and tNCV had increased in both groups. These results are in agreement with Benchev [13] , who found that the mean increase in total mMCA was 0.42 cm 2 and the mean increase in the tNCV was3.83 cm 3 .

Intraoperative blood loss during PAT was statistically significantly less than SMR, which is consistent with Hegazy et al. [19] , who reported an average 30-ml blood loss during microdebrider turbinoplasty.

The mean operative times for each side were 11.1 8 1.7 and 29.4 8 4.7 min in the PAT and SMR groups, re-spectively, which is in agreement with Hegazy et al. [19] . They reported that a mean operative time for each turbi-nate of about 8 min (using microdebrider turbinoplasty), which was statistically significantly shorter than SMR [19] .

Nasal crust findings showed no statistically signifi-cant difference between both groups; however, this is not in agreement with Chen et al. [2] , who found that postop-erative crusts developed more frequently after SMR.

Our results confirmed that PAT is as equally safe and effective as submucosal resection in relieving nasal ob-struction and enabling optimal volume reduction with preservation of function of the inferior turbinate. More-over, PAT offers more precision gentleness and control, and less postoperative discomfort.

The disadvantages of PAT are summarized as follows: (1) the high cost of microdebrider blades; (2) the device is less common in surgical centers; (3) it requires special training on the technique and operating the device; (4) it needs visualization of the inferior turbinate (especially when working on the posterior section) by nasal endos-copy.

Disclosure Statement

The authors report no conflicts of interest. D

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