Abstract
Over the years many surgical techniques have been described in the literature for the treatment of inferior turbinate hypertrophy (ITH) but the debate for ideal procedure is still on. In our study we are comparing two surgical procedures namely submucosal resection (SMR) of inferior turbinate and Powered inferior turbinectomy (PT) for the management of ITH. Surgical procedures are to be analyzed in terms of results and complications by subjective and Objective assessment. A prospective study was conducted from 1st December 2011 to 1st June 2013. Subjective assessment of nasal obstruction was done by visual analogue scoring before surgery and graded into none, mild, moderate, and severe. Patients were also subjected to nasal endoscopy for objective assessment of inferior turbinate size and graded as I, II, III. A total of 60 patients were operated (30 patients in each group), patients in Group A underwent SMR and in Group B patients PT was performed. Patients were assessed for various parameters like age, gender, laterality, intra operative and postoperative complications. Overall improvement of 66.7% in Nasal Obstruction and 76.7% in size of inferior turbinate was seen in Group A, whereas improvement of 90% in nasal Obstruction and 83.3% in size of turbinate was seen in Group B. Both SMR and PT are efficient methods for relieving nasal obstruction related to ITH. However, the results in our study confirm that PT is a safe and effective procedure in relieving nasal obstruction and enabling optimal volume reduction with preservation of function of the inferior turbinate.
Keywords: Inferior turbinate hypertrophy, Powered turbinectomy, Submucosal resection, Turbinoplasty
Introduction
Nasal obstruction is one of the most frequent complaints in Otorhinolaryngology and it is associated with structural abnormalities of the septum and lateral wall of the nose. The association of septal deviation with inferior turbinate hypertrophy on the opposite side of the septum, in a vicarious way, is a frequent finding in daily practices. Inferior turbinate surgeries are advocated for relief of symptoms in patients with chronic nasal congestion [1]. Today, turbinectomy/turbinoplasty is the most frequent procedure in otorhinolaryngology’s practice and is recognized as an effective treatment for nasal obstruction secondary to hypertrophic rhinitis [2]. The main goal of turbinate surgery is to relieve the patient’s symptoms and preserve the mucosal surfaces and Submucosal resection (SMR) turbinoplasty comes closest to meeting these targets [3, 4].
Powered turbinectomy (PT) offers preservation of both the mucosa and the anatomy/physiology of the turbinate, which in turn leads to a very short postoperative period and reduced crust formation [5–7].
Our study aims to analyze the surgical procedures i.e. SMR and PT in terms of results and complications by subjective (improvement of nasal obstruction) and Objective assessment (reduction in the size of inferior turbinate).
Methods
A prospective study from December 2011 to June 2013 was conducted on a total of 60 patients at Raja Rajeshwari Medical College and Hospital, Mysore Road, Bangalore. Patients were explained in detail about the surgical procedures, written informed consent was taken and were divided into 2 Groups, Group A (patients who underwent SMR) and Group B (patients who underwent PT).
Inclusion Criteria
Patients aged between 18 and 50 years of either sex, with nasal obstruction and inferior turbinate hypertrophy not responding to medical treatment with or without septal deviation (Fig. 1).
Fig. 1.
a, b Intra operative steps during SMR
Exclusion Criteria
Nasal obstruction with inferior turbinate hypertrophy in Patients aged below 18 years, Sinonasal polyposis, fungal sinusitis, neoplasms of the nose, chronic sinusitis, and medically unfit patients (Fig. 2).
Fig. 2.
a, b Intraoperative steps during powered turbinectomy
Patients during the study period with features of nasal obstruction and inferior turbinate hypertrophy were treated with topical decongestants and antihistaminics for a period of 6 weeks. Those who did not improve with medical treatment were included in our study. Subjective assessment of nasal obstruction was done by visual analog scoring before surgery and graded into none, mild, moderate, and severe [8]. Patients were also subjected to nasal endoscopy for objective assessment of the inferior turbinate size and graded as I, II, III [9].
All the patients were operated under general anesthesia. 4% Xylocaine solution was applied via surgical neuro patties around the turbinate for topical anesthesia. Local infiltration was done with 1% lidocaine with 1:100,000 epinephrine (Table 1).
Table 1.
Pre-operative assessment
| Pre-operative assessment | Group I (SMR) (n = 30) | Group II (PT) (n = 30) | ||
|---|---|---|---|---|
| No | % | No | % | |
| Nasal obstruction | ||||
| None | 0 | 0.0 | 0 | 0.0 |
| Mild | 0 | 0.0 | 0 | 0.0 |
| Moderate | 12 | 40.0 | 10 | 33.3 |
| Severe | 18 | 60.0 | 20 | 66.7 |
| Size of inferior turbinate | ||||
| I | 0 | 0.0 | 0 | 0.0 |
| II | 13 | 43.3 | 11 | 36.7 |
| III | 17 | 56.7 | 19 | 63.3 |
SMR was performed using nasal endoscopes, the incision was made with a no 11 blade along the inferior edge of the turbinate and was carried down to bone far posteriorly up to the anterior nasal root. The mucosa was then elevated from both the medial and lateral surfaces of the turbinate bone using a Cottle’s elevator and turbinate bone was resected with the help of turbinate scissors. The flaps were cauterized and anterior nasal packing was placed for 48 h, simultaneous with systemic antibiotic treatment.
Group B patients were subjected to the same preoperative preparation as Group A patients. An incision was made with a no 15 blade vertically in the anterior aspect of the inferior turbinate. A submucosal pocket was created with sharp dissection on the medial surface of the bony turbinate. The straight microdebrider (4-mm tip with trucut blade) was applied through the incision. The bony turbinate and some of the submucosal tissue was debrided at 3000-cps oscillating mode in a ventro-caudal (anteroposterior) manner. Debridement was performed with the blade positioned laterally from the submucosal plane. Particular attention was paid to preserve the mucosal flap. The reduction in the size of the inferior turbinate was easily recognized immediately after the procedure. Anterior nasal packs were used for 48 h (Table 2).
Table 2.
Intra operative complications
| Intra operative complications | Group I(SMR) (n = 30) | Group II(PT) (n = 30) | ||
|---|---|---|---|---|
| No | % | No | % | |
| Bleeding | 6 | 20.0 | 4 | 13.3 |
| NASO lacrimal duct injury | 0 | 0.0 | 0 | 0.0 |
| Mucosal tears | 5 | 16.7 | 2 | 6.7 |
The improvement in nasal obstruction following surgery was assessed by visual analog scale and size of the inferior turbinate assessed by nasal endoscopy. All patients were assessed in the immediate postoperative period, post-operative week 1st and 8th post-operative week. Symptoms score was assessed and recorded at 1st week postoperatively (Table 3) and 8th week (Table 4).
Table 3.
Post-operative assessment at 1 week
| Post-operative assessment at 1 week | Group I (SMR) (n = 30) | Group II (PT) (n = 30) | ||
|---|---|---|---|---|
| No | % | No | % | |
| Crusting | 6 | 20.0 | 4 | 13.3 |
| Dryness of nose | 8 | 26.7 | 6 | 20.0 |
| Adhesion | 1 | 3.3 | 0 | 0.0 |
| Nasal obstruction | ||||
| None | 1 | 3.3 | 2 | 6.7 |
| Mild | 21 | 70.0 | 23 | 76.7 |
| Moderate | 5 | 16.7 | 3 | 10.0 |
| Severe | 3 | 10.0 | 2 | 6.7 |
| Size of inferior turbinate | ||||
| I | 19 | 63.3 | 23 | 76.7 |
| II | 9 | 30.0 | 6 | 20.0 |
| III | 2 | 6.7 | 1 | 3.3 |
Table 4.
Post-operative assessment at 8th week
| Post-operative assessment at 8 week | Group I (SMR) (n = 30) | Group II (PT) (n = 30) | ||
|---|---|---|---|---|
| No | % | No | % | |
| Crusting | 5 | 16.7 | 3 | 10.0 |
| Dryness of nose | 4 | 13.3 | 4 | 13.3 |
| Adhesion | 1 | 3.3 | 0 | 0.0 |
| Nasal obstruction | ||||
| None | 20 | 66.7 | 23 | 76.7 |
| Mild | 7 | 23.3 | 4 | 13.3 |
| Moderate | 1 | 3.3 | 2 | 6.7 |
| Severe | 2 | 6.7 | 1 | 3.3 |
| Size of inferior turbinate | ||||
| I | 23 | 76.7 | 25 | 83.3 |
| II | 6 | 20 | 5 | 16.7 |
| III | 1 | 3.3 | 0 | 0.0 |
Descriptive and inferential statistical analysis has been carried out in the present study. Chi square/Fisher Exact test has been used to find the significance of study parameters on a categorical scale between two or more groups. The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the data and Microsoft Word and Excel have been used to generate graphs, tables etc.
Results
In our study, the age of patients ranges from 18 to 50 years. The maximum number of cases were between 21 and 30 years (38.3%) followed by 31–40 years (35%) with a mean age of 31.21 years. Age distribution was comparable in both groups, samples are age-matched with P = 0.333 indicating that there was no statistically significant difference in the mean age of these two groups. In our study total numbers of males were 34(56.6%) and females were 26(43.3%). There was no statistically significant difference between male and female distribution. A total of 8 patients underwent right inferior turbinectomy, 4 patient’s left inferior turbinectomy and the rest bilateral inferior turbinectomy. In our study, 60% of the patients had nasal obstruction of severe grade and 40% of the patients had moderate grade of nasal obstruction in Group A. Whereas in Group B, 66.7% of the patients had severe grade of nasal obstruction and 33.3% of the patients had moderate grade of nasal obstruction (P value = 0.597). 56.7% of the patients had inferior turbinate hypertrophy of grade III and 43.3% of the patients had grade II hypertrophy in Group A. Whereas in Group B 63.3% of the patients had grade III hypertrophy and 36.7% of the patients had grade II hypertrophy of inferior turbinate (P value = 0.598).
Intraoperatively
Bleeding was seen in 20% of the patients in Group A, and 13.3% in Group B patients (P value = 0.488). Naso-lacrimal duct injury was not seen in both the Groups. Mucosal tears were seen in 16.7% of cases in Group A and 6.7% in Group B cases (Table 5).
Table 5.
Overall assessment of group I (SMR)
| Nasal obstruction | Pre-operative (n = 30) | Post-op 8 weeks (n = 30) | % change |
|---|---|---|---|
| Nasal Obstruction | |||
| None | 0 | 20 (66.7%) | + 66.7% |
| Mild | 0 | 7 (23.3%) | + 23.3% |
| Moderate | 12 (40.0%) | 1 (3.3%) | − 36.7% |
| Severe | 18 (60.0%) | 2 (6.7%) | − 53.3% |
| Size of inferior turbinate | |||
| I | 0 | 23 (76.7%) | + 76.7% |
| II | 13 (43.3%) | 6 (20%) | − 23.3% |
| III | 17 (56.7%) | 1 (3.3%) | − 53.4% |
Post-operative 48 h
Bleeding was seen in 6.7% of cases in Group A and 3.3% cases of Group B. Watering of the eyes was seen in 10% of cases in Group A and 3.3% in cases of Group B (Table 6).
Table 6.
Overall assessment of group II (PT)
| Nasal obstruction | Pre-operative (n = 30) | Post-op 8 weeks (n = 30) | % change |
|---|---|---|---|
| Nasal Obstruction | |||
| None | 0 | 23 (76.7%) | + 76.7% |
| Mild | 0 | 4 (13.3%) | + 13.3% |
| Moderate | 10 (33.3%) | 2 (6.7%) | 26.7% |
| Severe | 20 (66.7%) | 1 (3.3%) | − 63.4% |
| Size of inferior turbinate | |||
| I | 0 | 25 (83.3%) | + 83.3% |
| II | 11 (36.7%) | 5 (16.7%) | − 20.0% |
| III | 19 (63.3%) | 0.0 | − 63.3% |
Postoperatively 1st Week
Crusting in the nasal cavity was seen in 20% of the patients in Group A as compared to 13.3% patients in Group B whereas dryness of nose was noted more in Group A in 26.7% of cases of Group A and 20% of the patients of Group B. Adhesions were not seen in Group B cases and was present in only 3.3% of cases in Group A. Nasal obstruction was found to be none in 3.3% and 6.7% in Group A and Group B respectively and mild in 70% of cases of Group A and 76.7% of cases in Group B. 16.7% of cases were having moderate nasal obstruction in Group A, as compared to 10% of the patients in Group B. 10% of the cases still had severe nasal obstruction in Group A, when compared to 6.7% in Group B (P value = 0.794). Reduction in the size of inferior turbinate was noted, in Group A 63.3% of the cases were found to be in grade I when compared to 76.7% cases in Group B. There were 30% cases in Group A and 20% cases in Group B who were having grade II turbinate hypertrophy. While there were 6.7% of cases of grade III turbinate hypertrophy in Group A, there were 3.3% cases of grade III turbinate hypertrophy in Group B (P value = 0.388).
Postoperatively 8th Week
Crusting in the nasal cavity was seen in 17% of the patients in Group A as compared to 10% patients in Group B. Dryness of the nose was noted more in Group A in 13.3% of cases whereas 13.3% of the patients in Group B had similar complaints. Adhesions were not seen in Group B and were present in only 3.3% of patients in Group A. Nasal obstruction was found to be none in 66.7% of cases of Group A and 76.7% of cases in Group B. 23.3% of cases were having mild nasal obstruction in Group A, as compared to 13.3% of the patients in Group B. 3.3% of the cases still had moderate nasal obstruction in Group A, when compared to 6.7% in Group B. 6.7% of the patients had severe nasal obstruction in Group A while in Group B 3.3% of patients had the same (P value = 0.658). Reduction in the size of inferior turbinate was noted, in Group A 76.7% of the cases were found to be in grade I when compared to 83.3% cases in Group B. There were 20% cases in Group A and 16.7% cases in Group B who were having grade II turbinate hypertrophy. There were 3.3% of patients having grade III turbinate hypertrophy in Group A (P value = 0.748).
Overall Assessment
Improvement of 66.7% in Nasal Obstruction and 76.7% in size of inferior turbinate was seen in Group A (P < 0.001), whereas improvement of 90% in nasal Obstruction and 83.3% in size of turbinate was seen in Group B (P < 0.001).
Discussion
Inferior turbinate surgeries are advocated for relief of symptoms in patients with chronic nasal congestion, while the medical line of management mainly aims in symptomatic relief than cure. There are numerous studies which show the usefulness of different types of surgical procedures for reduction of the size of inferior turbinate [10–14]. An ideal procedure for turbinate reduction should reduce the turbinate effectively and be associated with minimal discomfort and complications. Powered turbinectomy has the advantages of mucosal preservation alongside controlled volume reduction, minimal trauma, reduced bleeding and enhanced precision providing marked improvements in nasal obstruction [15]. Powered turbinoplasty provides an effective, reliable, long-term improvement in nasal airway patency and relief of nasal obstruction, with minimal complications [16].
A total of sixty patients were included in our study, 30 patients in Group A who underwent SMR of turbinate and 30 patients in Group B who underwent PT. This study was conducted to assess the effectiveness of these two surgical procedures in terms of inferior turbinate reduction (objectively) and improvement of nasal obstruction (subjectively).
Age Distribution
In the present study age of patients ranges from 18 to 50 years. The maximum number of cases were between 21 and 30 years (38.3%). Age of the patients undergoing inferior turbinate reduction can be attributed to the underlying cause leading to both inferior turbinate hypertrophy and nasal obstruction as in cases of allergic rhinitis. Mean age Group of patients suffering from hypertrophic inferior turbinate was 30–40 years in a study reported by Khan et al. and Saad Bin Qamar et al. [17, 18]. In a study reported by Ahmed Hesham et al. [19] the mean age was 31 years which is consistent with our study. The reason for this because the onset of true inhalant allergen is rare in infancy and the geriatric population, but most common in the teen and young adult ages, peaking at around the age of 30 [20].
Sex Distribution and Laterality
The incidence of turbinate hypertrophy is more common in males as reported by Van Delden et al. [21] a finding consistent with this study. The incidence of hypertrophic inferior turbinate in males quoted by Khan et al. [17] was 73.3%. Ahmed Hesham et al. [19] in his study found 56.7% of patients were males which are on par with our study.
Intraoperative Complications
Bleeding was seen in 20% of the patients in Group A and 3.3% of the patients in Group B. Mild hemorrhage is the most frequent complication associated with submucosal resection of the inferior turbinate and occurs in 2–7% of patients [22]. Hegazy et al. [23] reported an average 30-ml blood loss during microdebrider turbinoplasty. In our study intraoperative blood loss during PT was statistically significantly less than SMR; this can be attributed to our surgical technique of powered turbinectomy in which submucosal pocket was examined endoscopically and bleeding points were cauterized. In our study, mucosal tears were seen in 16.7% of cases in Group A and 6.7% in Group B. In a review article done by Chang et al. [24] stated that maintenance of surface epithelium is necessary to reduce feared complications of crusting, synechiae, and osteitis that may result from bony exposure.
Post-operative Complications
Immediate follow up of the patients were done at after the removal of nasal packs and bleeding was seen in 6.7% of cases in Group A and 3.3% cases of Group B. Postoperative bleeding is a complication associated with all turbinate reduction techniques [25]. Nasal crust findings showed no statistically significant difference between both Groups; our results are in agreement with Chen et al. [26] who found that postoperative crusts developed more frequently after SMR. our results are in consistent with most of the studies regarding nasal crusting and dryness of nose. Nasal crusting is directly proportional to the exposed raw mucosal area which is seen more during the submucosal resection of the turbinate when compared with powered turbinectomy. Post-operative nasal douching and endoscopic cleaning promotes faster healing and fewer chances of synechiae formation. Watering of the eyes is a common complaint of the patients who undergo inferior turbinate reduction procedures since the nasal packs temporarily block tear ducts.
Assessment of Subjective Symptoms
Improvement of nasal obstruction in 66.7% of patients was statistically significant Group A and improvement of 90% were statistically significant within Group B. In our study, the difference in VAS was highly significant at 2 months compared to preoperative in both Groups. This means that much improvement of Group B patients compared to Group A occurred at 1st and 8th post-operative week. Sherman et al. [27] too in a study of nasal airway function post-operatively reported increased improvement with passage of time and found it to be maximum (80.26%) at two to 12 months follow-ups. House et al. [28] reported subjective improvement in nasal airway patency in 78% and the extent of relief was from 50% to complete relief. In a study by Friedman et al. [9], subjective relief of nasal obstruction was seen in 75% of cases who underwent powered turbinectomy. El Henawi et al. [29] in his comparative study between Power-assisted turbinoplasty and submucosal resection in the treatment of inferior turbinate hypertrophy observed 91.3% improvement in nasal obstruction in both Groups. Chen et al. [30] made comparison between intraturbinal microdebrider turbinoplasty and conventional submucosal in their study on 120 children and they found that both methods are effective in relieving nasal obstruction caused by inferior turbinate hypertrophy and concluded that microdebrider turbinoplasty is superior to conventional submucosal resection with regard to preserving the nasal mucosa. In our study the nasal obstruction was relived in 66.7% of cases in Group A was which is not consistent with other studies as it should be higher as shown in different studies using different methods of submucosal resection of turbinates. However, 90% improvement in nasal obstruction in Group B patients along with the above studies gives us an inference that powered turbinectomy provides a good sense of relief in terms of subjective symptomology.
Assessment of Objective Symptoms
Reduction in size of inferior turbinate in 76.7% of patients in Group A and reduction in the size of inferior turbinate in 83.3% cases was statistically significant. In a study by Friedman et al. [9] there were 74 (32%) grade II and 158 (68%) grade III inferior turbinates before surgery and 166 (72%) grade I and 66 (28%) grade II inferior turbinates after the surgery, all of the inferior turbinates exhibited a decrease in size that underwent powered turbinectomy. El Henawi et al. [29] in his comparative study observed reduction in turbinate size in 95.7% patients who underwent powered turbinectomy and reduction in turbinate size in 91.3% patients who underwent submucosal resection of inferior turbinate. Hesham et al. [19] reported 86.7% of the patients had reduced turbinate size in his study. As shown in the above studies and our study, Powered endoscopic turbinectomy provides excellent outcomes in a wide variety of patients with minimal morbidity. There is a significant improvement in nasal obstruction and reducing the bulk of the turbinate which lasts for a long time.
Conclusion
Chronic nasal airway obstruction is commonly due to inferior turbinate hypertrophy. When medical management fails surgery may be an effective treatment. A large number of surgical techniques in use to reduce turbinate size indicates there is no single technique, which is effective in all patients. There is no ‘gold standard’ nor is there any technique entirely free of side effects. Both Submucosal resection and Powered turbinectomy are efficient methods for relieving nasal obstruction related to inferior turbinate hypertrophy. However, the results in our study confirm that Powered turbinectomy is a safe and effective procedure in relieving nasal obstruction and enabling optimal volume reduction with preservation of function of the inferior turbinate. Moreover, Powered turbinectomy offers more precision gentleness and control, less postoperative discomfort and complications when compared to submucosal resection of the inferior turbinate.
Compliance with Ethical Standards
Conflict of interest
First Author and Co-Authors declare that they have no conflict of interest.
Ethical Approval
Research Involving Human Participants and/or Animals: Nil.
Informed Consent
Taken from patients.
Footnotes
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Contributor Information
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