Long-term Outcomes of Turbinate Surgery in Patients With Allergic Rhinitis: A Systematic Review and Meta-analysis

Sang Chul Park; Do Hyun Kim; Young Joon Jun; Soo Whan Kim; Hyeon-Jong Yang; Song-I Yang; Hyun Jung Kim; Dong-Kyu Kim

doi:10.1001/jamaoto.2022.3567

. 2022 Nov 17;149(1):15–23. doi: 10.1001/jamaoto.2022.3567

Long-term Outcomes of Turbinate Surgery in Patients With Allergic Rhinitis

A Systematic Review and Meta-analysis

Sang Chul Park ¹, Do Hyun Kim ², Young Joon Jun ³, Soo Whan Kim ², Hyeon-Jong Yang ⁴, Song-I Yang ⁵, Hyun Jung Kim ^6,^✉, Dong-Kyu Kim ^7,^8,^✉

¹Department of Otorhinolaryngology–Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea

²Department of Otolaryngology–Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

³Department of Otorhinolaryngology–Head and Neck Surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu-si, Republic of Korea

⁴Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University College of Medicine, Seoul, Republic of Korea

⁵Department of Pediatrics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea

⁶Institute for Evidence-Based Medicine, Korea University College of Medicine, Seoul, Republic of Korea

⁷Institute of New Frontier Research, Division of Big Data and Artificial Intelligence, Hallym University College of Medicine, Chuncheon, Republic of Korea

⁸Department of Otorhinolaryngology–Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea

Accepted for Publication: September 19, 2022.

Published Online: November 17, 2022. doi:10.1001/jamaoto.2022.3567

^✉

Corresponding Authors: Dong-Kyu Kim, MD, PhD, Division of Big Data and Artificial Intelligence, Department of Otorhinolaryngology–Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine (24253), 77, Sakju-ro, Chuncheon-si, Gangwon-do, Republic of Korea (doctordk@naver.com); Hyun Jung Kim, MPH, PhD, Institute for Evidence-Based Medicine, Department of Preventive Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Republic of Korea (moole02@naver.com).

Author Contributions: Drs Park and Dong-Kyu Kim had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Park, H. Yang, Dong-Kyu Kim.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Park, S. Kim, H. Yang, Dong-Kyu Kim, H. Kim.

Critical revision of the manuscript for important intellectual content: Park, Do Hyun Kim, Jun, H. Yang, S. Yang, Dong-Kyu Kim, H. Kim.

Statistical analysis: H. Yang, H. Kim.

Obtained funding: Park.

Administrative, technical, or material support: Do Hyun Kim, Jun, S. Kim, H. Yang, S. Yang, Dong-Kyu Kim.

Supervision: Park, Do Hyun Kim, S. Kim, H. Yang, Dong-Kyu Kim, H. Kim.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by a grant from the Korean Academy of Asthma, Allergy and Clinical Immunology.

Role of the Funder/Sponsor: The Korean Academy of Asthma, Allergy and Clinical Immunology had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors would like to thank all members of the Work Group for Rhinitis, the Korean Academy of Asthma, Allergy and Clinical Immunology.

^✉

Corresponding author.

PMCID: PMC9673023 PMID: 36394879

This systematic review and meta-analysis investigates the long-term outcomes and safety of turbinate surgery in patients with medically refractory allergic rhinitis.

Key Points

Question

What are the long-term outcomes of turbinate surgery in the treatment of patients with allergic rhinitis refractory to medical therapy?

Findings

In this systematic review and meta-analysis of 18 studies comprising 1411 patients, the treatment outcomes of turbinate surgery were maintained during long-term follow-up in patients with allergic rhinitis refractory to medical therapy, and the rate of complications was low.

Meaning

The findings could be useful in the preoperative counseling of patients with allergic rhinitis being considered for turbinate surgery.

Abstract

Importance

Turbinate surgery is an effective treatment for allergic rhinitis (AR) refractory to medical treatment. However, the long-term outcomes of turbinate surgery are still unclear and have not yet been confirmed by a meta-analysis and systematic review of the literature.

Objective

To investigate the long-term outcomes and safety of turbinate surgery in AR by performing a meta-analysis.

Data Sources

MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov were searched through April 2021.

Study Selection

Studies that analyzed turbinate surgery alone, had a follow-up period of more than 1 year, examined long-term efficacy of turbinate surgery, used current turbinate surgery methods, and were published in a peer-reviewed journal were included. Full-text reviews were performed by 2 independent reviewers. Conflicts were resolved by a third reviewer.

Data Extraction and Synthesis

Descriptive and quantitative data were extracted; weighted mean difference (WMD) was synthesized under a random-effects model. Heterogeneity was assessed using the Q statistic and the I² metric. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines.

Main Outcomes and Measures

The long-term outcomes of turbinate surgery on subjective nasal symptoms and objective parameters.

Results

Of the 3962 citations retrieved, 18 studies comprising 1411 patients were included. Findings showed significantly decreased symptom scores in nasal obstruction (WMD, 4.60, 95% CI, 3.43-5.76), rhinorrhea (WMD, 3.12; 95% CI, 1.97-4.28), sneezing (WMD, 2.64; 95% CI, 1.74-3.54), itching (WMD, 1.75; 95% CI, 1.20-2.30), and nasal resistance (WMD, 0.16; 95% CI, 0.08-0.24) and a significant increased total nasal volume (WMD, 0.96; 95% CI, 0.73-1.19). There was no significant difference in the occurrence of any complication. More than 1 year after surgery, the improvements in nasal obstruction (WMD, 5.18; 95% CI, 3.00-7.37), rhinorrhea (WMD, 3.57; 95% CI, 1.78-5.37), and sneezing (WMD, 2.95; 95% CI, 1.58-4.32) were maintained.

Conclusions and Relevance

In this systematic review and meta-analysis, turbinate surgery was associated with positive outcomes in AR and maintained the association during long-term follow-up. The rate of complications is also low. These findings can guide the preoperative counseling of patients with AR being considered for turbinate surgery.

Introduction

Allergic rhinitis (AR) is a common inflammatory disorder characterized by 2 or more of the following symptoms: nasal obstruction, nasal itching, rhinorrhea, and/or sneezing.^1,2 Allergic rhinitis can hamper the ability to concentrate on school and work tasks and interfere with sleep; in addition, it can affect asthma control, causing a heavy economic burden on health care systems. Treatment of AR comprises allergen avoidance, pharmacotherapy, immunotherapy, and combination therapy, according to the severity of symptoms.^1,2 Sometimes, if medical treatment fails to relieve nasal obstruction because of hypertrophy of the inferior turbinate, surgical reduction can be performed to control allergic symptoms.^2,3

Hypertrophy of the inferior turbinate has long been established as the main cause of nasal congestion because it can reduce nasal airflow.^4,5 Mucosal hypertrophy also underlies many of the specific and interrelated factors that contribute to nasal congestion, as well as other symptoms. For this reason, if patients with AR with hypertrophy of the inferior turbinate have undergone failed medical therapy, physicians may consider turbinate surgery.⁶ Generally, nasal obstruction is the symptom that is most refractory to medical management in patients with AR³; it can also be the most troublesome. Although surgery cannot eliminate the inflammatory origins of AR, improving nasal patency could reduce the edematous mucosa and alleviate allergic symptoms, such as nasal obstruction and rhinorrhea.² Turbinate surgery relieves allergic symptoms in patients with medically refractory AR,^7,8,9,10 and various surgical methods for turbinate surgery have recently been introduced.^2,6

However, to date, there have been few studies conducted on the long-term clinical efficacy of turbinate surgery. Additionally, to our knowledge, a systematic review and meta-analysis of the long-term therapeutic outcomes of turbinate surgery on AR has not yet been published. Therefore, in the present study, we performed a systematic review and meta-analysis to determine whether the therapeutic outcomes of turbinate surgery in patients with AR can be maintained in the long term.

Methods

Search Strategy

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines,¹¹ and the PRISMA checklist was used to report the study findings (eTables 1 and 2 in the Supplement). Details of the protocol for this systematic review were registered in the International Prospective Register of Systematic Reviews (CRD42022329747). There are no amendments to the information provided at registration. An extensive search of MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov was performed to identify relevant articles published before April 19, 2021. Each relevant publication was screened for references to other applicable publications. The search was not limited to studies in a specific language or publication year. Detailed information on our search strategy, including the keywords, is provided in eMethods in the Supplement. Written informed consent was waived by the institutional review board because the study used previously published and deidentified data.

Study Selection

All original articles concerning turbinate surgery in patients with AR were included in this systematic review. Studies were included if they met the following criteria: (1) they analyzed turbinate surgery alone, because we aimed to focus on the effect of turbinate surgery in rhinitis; (2) they had a follow-up period of more than 1 year, to examine long-term outcomes of turbinate surgery; (3) they used current turbinate surgery methods, such as radiofrequency or microdebriders; and (4) they were published in a peer-reviewed journal. The exclusion criteria were as follows: (1) studies that described surgeries combined with other procedures, such as septoplasty for septal deviation, endoscopic sinus surgery for chronic rhinosinusitis, vidian neurectomy for intractable rhinorrhea, and pharynx surgery for obstructive sleep apnea; (2) those that did not use current surgical methods, such as laser surgery, submucosal diathermy, argon plasma surgery, cryotherapy of the posterior nasal nerve, or ultrasound (high-intensity focused ultrasound); and (3) reviews, editorials, and guidelines. Article titles and abstracts were extracted, and full-text reviews were performed by 2 independent reviewers (S.C.P. and D.K.K.). Conflicts were resolved by a third reviewer (H.J.K.).

Data Extraction

The Population, Intervention, Comparison, and Outcome (PICO) statement is provided in eTable 3 in the Supplement. Data were extracted using a predefined data extraction form. The article title and reference details (author, publication year, country, and journal), study design, population characteristics (age and number of subjects in the study), and method of surgery follow-up were extracted. We also extracted subjective symptom scores (eg, visual analog scale [VAS], sinus and nasal quality-of-life [QOL] survey [SN-5], rhinoconjunctivitis QOL questionnaire [RQLQ], and Japanese allergic rhinitis QOL standard questionnaire [JRQLQ]) for nasal obstruction, rhinorrhea, sneezing, and itching; objective parameters, including total nasal resistance and nasal cavity volume, were measured by anterior rhinomanometry and acoustic rhinometry, respectively. Data were extracted by 2 independent reviewers (S.C.P. and D.K.K.) and reexamined by a third reviewer (H.J.K.). Data extracted from the included studies are provided in eTable 4 in the Supplement.

Risk of Bias

The risk of bias in the nonrandomized clinical trials was assessed using the Risk Of Bias In Nonrandomized Studies of Interventions (ROBINS-I) tool.¹² The tool assessed the risk based on the following options: “low risk of bias,” “moderate risk of bias,” “serious risk of bias,” “critical risk of bias,” or “no information.” The items comprised 7 bias domains: bias due to confounding, bias in the selection of participants for the study, bias in the classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in the measurement of outcomes, and bias in the selection of reported results. Risks across studies were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.¹³ Sensitivity analysis was conducted according to the risk of bias (eFigure 1 in the Supplement).

Statistical Analysis

The main outcomes in this study were derived from the results of the longest follow-up period in each original article. Moreover, to resolve the heterogeneity of each outcome measurement period, a subgroup analysis was performed according to the follow-up period. All statistical analyses were performed using Stata, version 15/MP (StataCorp LLC). The prognosis outcomes are displayed in forest plots using the corresponding 95% CIs. The weighted mean difference (WMD) in parameters before and after surgery was analyzed as a continuous variable using various inverse methods, with a combined estimate of mean difference. The I² statistic and Cochran Q test were used to assess statistical heterogeneity. Heterogeneity was quantified as low, moderate, and high with upper limits of 25%, 50%, and 75% for I², respectively. A funnel plot was used to investigate for publication bias. The data were prepared by conversion according to the Cochrane Handbook.¹⁴ To synthesize results and provide a rationale for the choice, a random method was used, considering heterogeneity of data due to the varied methods of surgery and differing proficiencies of surgeons. Statistical significance was set at P < .05 with 2-tailed tests.

Results

The initial literature search yielded 3962 studies after removing duplicates. After the abstract and full-text reviews, 18 studies comprising 1411 patients met the final inclusion criteria for the meta-analysis (Figure 1). We identified 12 case series, 5 randomized clinical trials, and 1 prospective cohort study that met the inclusion criteria (Table 1).^{15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32} In the present study, to identify the long-term outcomes of turbinate surgeries for AR, we compared preoperative and postoperative results in the same manner regardless of the study design. Thus, we ensured an appropriate number of patients in each group.

Figure 1. — PRISMA indicates Preferred Reporting Items for Systematic Reviews and Meta-analyses.

Table 1. Study Characteristics of Turbinate Surgery in Patients With Allergic Rhinitis.

Source	Level of evidence, study design	No. of patients	Age, mean (range), y	Follow-up	Type of surgery
Manzi et al,¹⁵ 2017, US	IV, case series	23	11.2 (4.8-17.6)	1.5 (Median, 1.6) y	Microdebrider with outfracture
Neri et al,¹⁶ 2016, Italy	IV, case series	18	36.77 (15-79)	4 y	Microdebrider
Banhiran et al,¹⁷ 2015, Thailand	Ib, RCT	57	46.2 (23-82)	1 y	Radiofrequency (TCRF, 25; BRF, 32)
Arganbright et al,¹⁸ 2015, US	IV, case series	63	10.5 (1.2-17.9)	4.55 (0.63-10.68) y	Radiofrequency, 72; microdebrider, 19; PTR, 21; all with outfracture
Deenadayal et al,¹⁹ 2014, India	IV, case series	200	NM (11-59)	2 y	Radiofrequency
Assanasen et al,²⁰ 2014, Thailand	IV, case series	45	31 (20-45)	3 y	Radiofrequency with outfracture
Akdag et al,²¹ 2014, Turkey	IV, case series	98	NM (17-70)	2 y	Radiofrequency
Lee,²² 2013, Korea	Ib, RCT	60	Intraturbinal, 32.3 (17-59); extraturbinal, 29.8 (15-61)	1 y	MAIT (intraturbinal, 30; extraturbinal, 30)
Kojima et al,²³ 2013, Japan	IV, case series	95	27 (11-75)	12.4 mo	Radiofrequency
Garzaro et al,²⁴ 2012, Italy	IV, case series	35	47 (18-76)	2 y	Microdebrider
Gunhan et al,²⁵ 2011, Turkey	Ib, RCT	55	34.8 (21-51)	Mean (SD), 14.2 (2.1) [range, 13-16] mo	INS, 27; turbinoplasty (radiofrequency), 28
Lin et al,²⁶ 2010, Taiwan	IV, case series	101	29.1	5 y	Radiofrequency
Liu et al,²⁷ 2009, Taiwan	Ib, RCT	120	34.8 (18-53)	3 y	MAIT, 60; RAIT, 60
Wu et al,²⁸ 2008, Taiwan	IIb, cohort	70	35.1 (12-69)	1 y	Microdebrider
Chen et al,²⁹ 2008, Taiwan	Ib, RCT	160	39.2 (19-61)	3 y	SR, 60; MAITL, 60
Huang et al,³⁰ 2006, Taiwan	IV, case series	50	31.2 (8-61)	1 y	Microdebrider
Lin et al,³¹ 2003, Taiwan	IV, case series	101	29.5 (11-70)	12-26 mo	Radiofrequency
Mori et al,³² 1999, Japan	IV, case series	60	25.9	1 y	Submucous turbinectomy

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Abbreviations: BRF, bipolar radiofrequency; INS, intranasal steroid; MAIT, microdebrider-assisted inferior turbinoplasty; MAITL, microdebrider-assisted inferior turbinoplasty with lateralization; NM, not mentioned; PTR, partial turbinate resection; RCT, randomized clinical trial; SR, submucosal resection; TCRF, temperature-controlled radiofrequency.

Therapeutic Outcomes of Turbinate Surgery on Subjective Nasal Symptoms

Among 18 studies, we analyzed the surgical therapeutic effect for studies that used the same subjective symptom score (VAS score: 0 for no symptoms to 10 for the most severe symptoms) (Figure 2). Nine studies analyzed the outcomes of turbinate surgery on nasal obstruction, showing a significant decrease after surgery compared with before turbinate surgery (WMD, 4.60; 95% CI, 3.43-5.76; I² = 99.6%).^{16,17,22,25,26,27,28,29,31} Rhinorrhea also decreased significantly after surgery compared with before turbinate surgery in 6 studies (WMD, 3.12; 95% CI, 1.97-4.28; I² = 99.3%).^{17,22,26,27,29,31} In addition, we found a significant decrease in sneezing in 6 studies^{17,22,26,27,29,31} (WMD, 2.64; 95% CI, 1.74-3.54; I² = 98.9%) and itching in 3 studies^22,26,31 (WMD, 1.75; 95% CI, 1.20-2.30; I² = 87.4%) after turbinate surgery.

Figure 2. — Weights are from random-effects analysis. BRF indicates bipolar radiofrequency; MAIT, microdebrider-assisted inferior turbinoplasty; MAITL, MAIT with lateralization; MAST, multiple-antigen simultaneous test; RAIT, radiofrequency-assisted inferior turbinoplasty; SR, submucosal resection; TCRF, temperature-controlled radiofrequency; WMD, weighted mean difference.

Therapeutic Outcomes of Turbinate Surgery on Objective Parameters

To identify the improvement in objective nasal function after turbinate surgery, we selected 6 studies with scores of nasal resistance and total nasal volume (eFigure 2 in the Supplement). Nasal resistance was significantly lower after turbinate surgery compared with that before surgery (WMD, 0.16; 95% CI, 0.08-0.24; I² = 98.0%).^{16,17,24,25,27,29} Turbinate surgery was also associated with a significant increase in total nasal volume in 3 studies (WMD, 0.96; 95% CI, 0.73-1.19; I² = 66.5%).^17,22,28

Complications of Turbinate Surgery

To determine the safety of turbinate surgery, we analyzed the incidence of complications (eFigure 3 in the Supplement). Out of a total of 18 studies, there were no postoperative complications in 8 studies.^{16,17,20,24,25,26,30,31} Of the 8 studies that reported postoperative complications, none reported serious complications.^{18,19,21,22,23,27,28,29} There were no descriptions of postoperative complications in 2 studies.^15,32 Bleeding was reported to occur at a frequency of 40 out of 1000 patients (rate, 0.04; 95% CI, 0.01-0.07; P = .08; I² = 51.9%), which was described as easily controlled in most studies.^19,22,23,28 The crusting occurred at a rate of 170 out of 1000 patients (rate, 0.17; 95% CI, 0.05-0.29; P < .001; I² = 87.5%).^19,27,29 Nasal dryness occurred at a frequency of 20 out of 1000 patients (rate, 0.02; 95% CI, −0.01 to 0.05; P = .79; I² = 0%).^27,29

Therapeutic Outcomes of Turbinate Surgery According to Follow-up Period and Surgical Method

We investigated the maintenance of improvement in each allergic symptom during the follow-up period (Figure 3). Patients who underwent turbinate surgery maintained a decrease in nasal obstruction for more than 3 years after turbinate surgery (WMD, 5.18; 95% CI, 3.00-7.37; I² = 100%).^16,26,27,29 A significant decrease in rhinorrhea was also maintained for more than 3 years after turbinate surgery (WMD, 3.57; 95% CI, 1.78-5.37; I² = 100%).^26,27,29 In addition, a decrease in sneezing was sustained from 3 months to 3 years postoperatively (WMD, 2.95; 95% CI, 1.58-4.32; I² = 99%).^26,27,29 Moreover, patients who underwent turbinate surgery did not show improvement in total nasal volume 1 month after turbinate surgery (WMD, 0.12; 95% CI, −0.53 to 0.77; I² = 0%)¹⁷ but did show improvement in total nasal volume 1 year after turbinate surgery (WMD, 0.96; 95% CI, 0.73-1.19; I² = 66%).^17,22,28 Next, we examined the outcomes of turbinate surgery according to the surgical method. In all parameters, superior results were observed in the microdebrider group compared with the radiofrequency group (eTable 5 in the Supplement).

Quality Assessment and Certainty of the Evidence

All the outcome parameters and complications analyzed in the studies are summarized in Table 2. The risk of bias in the included studies is shown in eFigure 4 in the Supplement. To determine the robustness of the risk of bias, we also performed the sensitivity test using only subjective parameters except objective ones (eFigure 1 in the Supplement). The Egger test indicated no publication bias. For bias due to confounding, 8 studies were judged to have serious or critical risk,^{15,16,17,18,19,20,21,24} and 4 had moderate risk.^22,26,31,32 For bias in selection of participants for the study, 8 studies had serious or critical risk.^{15,17,18,20,23,24,26,31} For bias in classification of interventions and due to deviations from intended interventions, all studies had low risk. For bias due to missing data, 10 studies had serious or critical risk.^{15,17,18,20,23,24,26,27,28,31} For bias in the measurement of outcomes, all studies were judged to have serious or critical risk, while for bias in the selection of reported results, 7 had serious or critical risk.^{15,18,19,20,21,26,31} Some outcomes showed heterogeneity (Figure 2A and B), and some showed imprecision (eFigure 3 in the Supplement). Therefore, based on the risk of bias in individual studies, the certainty of the evidence for outcomes and complications is very low.

Table 2. Long-term Outcomes of Turbinate Surgeries in Patients With Allergic Rhinitis: Summary of Findings.

Outcomes	Illustrative comparative risks (95% CI)^a		Mean difference (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)^b	Comments
Outcomes	Assumed risk, control	Corresponding risk, surgery	Mean difference (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)^b	Comments
Nasal obstruction, scale from 0 to 10	7.46 (5.87-9.06)	The mean nasal obstruction in the intervention groups was 4.60 higher (3.43-5.76 higher)	4.60 (3.43-5.76)	742 (8 Studies)	Very low	VAS score: 0 for no symptom to 10 for the most severe symptom
Rhinorrhea, scale from 0 to 10	6.00 (5.04-6.96)	The mean rhinorrhea in the intervention groups was 3.12 higher (1.97-4.28 higher)	3.12 (1.97-4.28)	599 (5 Studies)	Very low
Sneezing, scale from 0 to 10	5.47 (4.90-6.04)	The mean sneezing in the intervention groups was 2.64 higher (1.74-3.54 higher)	2.64 (1.74-3.54)	599 (5 Studies)	Very low
Nasal itching, scale from 0 to 10	4.44 (3.70-5.18)	The mean nasal itching in the intervention groups was 1.74 higher (1.20-2.30 higher)	1.74 (1.20-2.30)	262 (2 Studies)	Very low
Nasal resistance, Pa/mL/s	0.51 (0.13-0.89)	The mean nasal resistance in the intervention groups was 0.16 higher (0.08-0.24 higher)	0.16 (0.08-0.24)	445 (6 Studies)	Very low	NA
Total nasal volume, cm³	7.99 (3.78-12.20)	The mean total nasal volume in the intervention groups was 0.97 higher (0.75-1.19 higher)	0.97 (0.75-1.19)	187 (3 Studies)	Very low	NA
Bleeding	0 per 1000	30 per 1000 (10-60 per 1000)	0.03 (0.01-0.06)	425 (4 Studies)	Very low	NA
Crust	0 per 1000	170 per 1000 (50-290 per 1000)	0.17 (0.05-0.29)	340 (3 Studies)	Very low	NA
Nasal dryness	0 per 1000	20 per 1000 (10-50 per 1000)	0.02 (−0.01 to 0.05)	140 (2 Studies)	Very low	NA

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Abbreviations: GRADE, Grading of Recommendations Assessment, Development and Evaluation; NA, not applicable.

^{^a}

The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

^{^b}

GRADE Working Group grades of evidence: high quality: further research is very unlikely to change our confidence in the estimate of effect; moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate; very low quality: we are very uncertain about the estimate.

Discussion

The results of this systematic review and meta-analysis indicate that turbinate surgery in patients with AR is associated with improvement in subjective symptoms and objective parameters during long-term follow-up and is associated with a low risk of adverse effects. However, the evidence supporting these findings is of very low reliability based on the risk of bias across trials and the inconsistency of study designs. However, in the field of surgery, it is anticipated that clinical studies are of heterogeneous study design, and randomized clinical study designs are difficult to implement. For these reasons, the effect size regarding the long-term therapeutic outcomes of turbinate surgery in patients with AR is clinically meaningful despite statistical reliability being low. Therefore, although turbinate surgery is not considered an initial treatment for patients with AR, these findings may imply a positive role of turbinate surgery in patients with AR refractory to medical management, as previously described.^2,33

To date, the long-term success of turbinate surgery remains unclear. In this study, we defined the duration of long-term follow-up as greater than 12 months. The duration of follow-up in published studies ranges from 3 months to several years, and some studies have reported that the results from variable follow-ups are combined. In this systematic review, we included studies on turbinate surgery that were performed in patients who were not responsive to medical therapy and showed that the duration of medication was varied, although 3 months of conservative treatment was most commonly observed. Additionally, to focus on the outcomes of turbinate surgery and to rule out the possibility of bias from other surgeries, we excluded studies in which turbinate surgery was combined with other procedures, such as septoplasty, endoscopic sinus surgery, and vidian neurectomy. Moreover, the septum is considered to have a low contribution to allergen deposition and mucociliary clearance and is not a major contributor to the disease process or nasal obstruction seen in AR.^2,3

For this meta-analysis, we included studies that used the VAS score as the primary outcome measure. However, several previous studies have used other parameters besides the VAS score. One prior study²³ reported that the nasal congestion symptom score measured using the JRQLQ showed a significant improvement after surgery in patients with perennial or seasonal AR compared with before surgery. However, runny nose significantly improved in patients with perennial rhinitis but not seasonal rhinitis.²³ Another study used the SN-5 survey to obtain the nasal congestion symptom score, revealing significantly improved allergic symptoms after surgery.¹⁵ Additionally, Mori et al³² revealed that the total symptom score and nasal congestion symptom score, using a subjective grade measuring nasal stiffness, were significantly reduced in patients with perennial AR after surgery. Consistent with these studies, our meta-analysis revealed that the largest mean difference comparing before and after turbinate surgery was for nasal obstruction (4.60), followed by rhinorrhea (3.12), sneezing (2.64), and itching (1.75). This indicates that that turbinate surgery could be effective for patients with medically refractory AR who mainly experience nasal obstruction.

Since the first study reported in 1882, numerous surgical methods for the reduction of hypertrophic inferior turbinates have been introduced.^4,6,34 Controversy still exists around optimal surgical techniques, but the contemporary literature mainly focuses on radiofrequency ablation and the use of microdebriders because they can preserve the physiological function of nasal mucosa.^6,35 A recently published meta-analysis showed that microdebrider-assisted turbinoplasty was associated with a better outcome, particularly during long-term follow-up, when compared with radiofrequency.³⁶ This is consistent with the findings of our meta-analysis (eTable 5 in the Supplement).

Complications such as atrophic rhinitis and empty nose syndrome have driven practitioners away from turbinectomy.³⁷ Ultrasound turbinate reduction has been reported, but long-term follow-up data are lacking.³⁸ Turbinate surgery is also safe and can even be performed on children^15,18; it can be performed in an outpatient clinic setting, and long-term hospitalization is not required, even if surgery is carried out during hospitalization. However, it is necessary to explain to patients in advance that adverse effects, such as bleeding, crusting, and nasal dryness, may occur after surgery.^3,4 The complication rate in our meta-analysis was low (0.04, 0.17, and 0.02, for bleeding, crusting, and dryness, respectively). Although the complications are not serious and resolve within a few months, patient adherence may be reduced when complications occur; thus, physicians should carefully monitor the possibility of postoperative complications. In addition, regular follow-up with nasal dressing is required to help heal the turbinate mucosa during the recovery period.

Limitations

This study has some limitations. First, there was a lack of control groups that did not undergo surgery. It would be ideal to compare the outcomes of surgery between nonsurgery and surgery groups. However, owing to the characteristics of the studies investigating turbinate surgery, there were no available articles evaluating long-term outcomes in surgery and nonsurgery groups. Moreover, the effect of surgery has not been overestimated because of the lack of spontaneous AR remission. Patients with AR who received no treatment showed worsening of symptoms, even developing asthma.³⁹ Further, fewer preschool-aged children with AR entered remission than those with nonallergic rhinitis.⁴⁰ Second, there was heterogeneity of data due to the varied methods of turbinate surgery, differing proficiency of surgeons, and different time points of outcome measurement. However, this heterogeneity showed a tendency toward a positive effect of surgery. Nevertheless, these limitations are unavoidable in studies regarding specific surgical procedures owing to ethical issues. We also evaluated publication bias for the possibility that only articles with positive results could have been published, and the Egger test indicated no publication bias. Third, the diagnostic criteria of AR in the included studies were not unified. Heterogeneous methods were used to diagnose AR through the detection of antigen-specific antibodies, including the multiple-antigen simultaneous test, radioimmunosorbent test, ImmunoCAP (ThermoFisher Scientific), and skin prick test. This variability could have affected the accuracy of AR diagnosis among included patients. Finally, in this study, we could not further subgroup analysis according to age because several studies included the mixture data of adult and pediatric patients.^{16,19,22,23,28,30,31} Subgroup analysis is warranted to further investigate the outcomes of turbinate surgery in adults and children.

Conclusions

In this systematic review and meta-analysis, findings suggest that turbinate surgery is associated with positive long-term outcomes in patients with AR refractory to medical therapy, and the therapeutic outcomes can be maintained long term. Moreover, although it is associated with sufficient therapeutic outcomes, turbinate surgery has a very low complication rate. Therefore, these findings could be useful in the preoperative counseling of patients with AR being considered for turbinate surgery.

Supplement.

eMethods. Supplementary Methods

eTable 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist

eTable 2. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for abstracts

eTable 3. Population, Intervention, Comparison, Outcome (PICO) Statement

eTable 4. Details of data extracted from the included studies

eTable 5. Long-term effect of turbinate surgeries according to the surgical methods

eFigure 1. Result of sensitivity analysis conducted according to the risk of bias.

eFigure 2. Forest plots comparing objective parameters before and after turbinate surgery

eFigure 3. Forest plots for complications after turbinate surgery.

eFigure 4. Bar graph presenting the risk of bias domain as percentages in all included studies

Click here for additional data file.^{(1.1MB, pdf)}

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