Role of CO₂ Laser in the Management of Symptomatic Hypertrophy of Inferior Nasal Turbinates

Abstract

The aim of this study was to evaluate the efficacy of CO₂ laser ablation in the management of symptomatic hypertrophied inferior nasal turbinates. This prospective observational study was carried out on 53 patients with symptomatic ITH refractory to medical management in the Department of Otorhinolaryngology and Head and Neck Surgery, SMHS Hospital, Srinagar, J&K from January 2017 to June 2018 after obtaining ethical clearance. The pre and postoperative subjective assessment of the nasal obstruction included nasal obstruction symptom evaluation scale (NOSE) and the visual analogue scale (VAS). Lund and Kennedy endoscopic scoring was used to assess postoperative intranasal crusting and tissue healing. Postoperative pain was evaluated using VAS. All patients underwent CO₂ laser spot ablation of hypertrophic inferior turbinates under local anesthesia in an outpatient setting. The patients were followed up at 2 weeks, 1 month and 3 months postoperatively. The VAS score for nasal obstruction improved from preop score of 6.05 (± 2.1) to 3.0 (± 1.01), 2.01 (± 0.90), 1.18 (± 0.40) at 2 weeks, 1 month and 3 months respectively in the postop period and the NOSE score also improved from preop score of 64.90 (± 13.29) to post-operative NOSE score of 18.96 (± 9.53) at 2 weeks, 9.81 (± 7.33) at 1 month and 5.09 (± 4.28) at 3 months. Difference between preoperative and postoperative NOSE and VAS scores was statistically significant (p < 0.05). There was minimal postoperative pain and intranasal crusting. Postoperative tissue healing was also good. CO₂ laser turbinoplasty is a safe and effective way of improving nasal flow. It offers more precision, gentleness, control and less intraoperative discomfort. CO₂ laser turbinoplasty meets all of the criteria for an ideal method for the treatment of nasal obstruction secondary to inferior turbinate hypertrophy with improvement of quality of life and reducing the risk of medical morbidity.

Introduction

Nasal obstruction caused by, hypertrophied inferior nasal turbinate (HIT) is one of the most common symptoms in otolaryngology. Medical treatment, including nasal drops, antihistamines, topical and systemic steroids, and allergen avoidance, is usually sufficient only for a short period of time. Therefore, surgery is necessary in many cases. A variety of surgical procedures have been mentioned for the reduction of hypertrophied inferior nasal turbinates [1–10].

The incidence of allergic and non-allergic rhinopathies has increased steadily over the past many years [11]. Allergic or non-allergic rhinitis causes chronic inflammation of the mucosa of nose which further leads to deposition of collagen in the submucosal tissue of the turbinates and remodelling of the turbinate bone. This results in development of inferior turbinate hypertrophy (ITH). Although it is not a life-threatening condition, chronic rhinitis can have a great impact upon patients’ quality of life and this is why an adequate treatment should be rapidly established [12, 13].

Turbinate surgery has been reported as the eighth common procedure in otolaryngology practice [14]. Most of the surgical techniques described for reduction of hypertrophied inferior turbinates are associated with a distinct risk of bleeding, pain, uncontrolled damage of the mucosa, and atrophic rhinitis, hence there is a need for less traumatic treatment. This can be accomplished by laser surgery, which offers the advantage of limited tissue trauma, less bleeding, and a high patient acceptance under outpatient conditions.

The CO₂ laser, which mainly cuts and ablates tissue, is used most often for vaporization of hypertrophied turbinates and occasionally for coagulation of small blood vessels in the milder forms of hereditary haemorrhagic telangiectasia [15].

A great variety of CO₂ laser surgical techniques is described in the literature. Selkin [16] used the CO₂ laser to resect the hypertrophied mucosa of the turbinate in a line (15–18 W), whereas Elwany et al. [3] almost completely vaporized the mucosa in the anterior one-third of the turbinate (20–30 W). Fukutake et al. [17] removed the entire mucosa of the inferior turbinates by evaporization (20–25 W), once in a week for 5 weeks.

The main aim of CO₂ laser turbinoplasty is preservation of a well-functioning mucosa, creating a sufficiently large air space, and maintenance of a physiological airway resistance. Thermal damage to the nasal mucosa from the laser energy causes scarring of the mucosal epithelium and in the submucosa, reducing the swelling capacity and secretory functions of the turbinate [18, 19]. The benefits of CO₂ laser surgery are minimal bleeding, good wound healing and high precision, no hospitalization and better long-term results.

Aims and Objectives

1. To compare the subjective improvement of nasal obstruction before and after surgery.

2. To assess the degree of nasal pain, degree of nasal crustations and tissue healing postoperatively.

Materials and Methods

This prospective observational study was carried out on 53 patients in the Department of Otorhinolaryngology and Head and Neck Surgery, SMHS Hospital, an associated hospital of GMC Srinagar, J&K from January 2017 to June 2018 after obtaining ethical clearance. This study was focussed on patients with symptomatic bilateral inferior turbinate hypertrophy who were refractory to medical treatment and all interventions were performed under local anaesthesia.

Sufficient informed consent and agreement in accordance with the Helsinki declaration was obtained from the patients. All patients were informed about the surgery, possible complications during surgery and post-operative complications.

Inclusion Criteria

1. Patients having unilateral or bilateral inferior turbinate hypertrophy.

2. Patients having history of recurrent nasal obstruction attributed to hypertrophy of inferior nasal turbinate whether allergic or non-allergic.

3. Patients not responding to conservative management of inferior turbinate hypertrophy.

Exclusion Criteria

1. Patients with previous history of nasal trauma, infectious rhinitis and sinusitis, concha bullosa, gross deviation of nasal septum or nasal polyposis, and malignancy of nose and paranasal sinuses, were excluded from the study.

2. Revision surgery on inferior turbinates.

3. Systemic disease contraindicating surgery.

4. Patient’s general condition not permitting surgery (including pregnancy).

5. Unwillingness for surgery.

Procedure

A detailed history including onset, duration and associated symptoms was obtained from the patients. The patients were subjected to thorough ENT examination including endoscopic evaluation of the nose, performed using a 0° endoscopic lens with 4 mm diameter under local anesthesia (lidocaine 10%) and vasoconstrictors (xylometazoline hydrochloride 0.1%) preoperatively and ‘at each follow-up of 2 weeks, 1 month and 3 months postoperatively.

In the present study, we used “Inferior Turbinate Classification System” for grading the amount of airway space that the anterior aspect of the inferior turbinate occupies relative to the total available airway space (Table 1).

Table 1.

25% (Grade 1–4) inferior turbinate classification system [20]

Grade	Turbinate/total airway space × 100 (%)
Grade 1	0–25
Grade 2	26–50
Grade 3	51–75
Grade 4	76–100

Assessment

The pre and postoperative subjective assessment of the nasal obstruction included nasal obstruction symptom evaluation scale (NOSE) and the visual analogue scale (VAS). The American Academy of Otorhinolaryngology has validated the questionnaire entitled “Nasal Obstruction Symptom Evaluation”, known as NOSE scale, the term used in this study (Table 2).

Table 2.

Nasal obstruction symptoms evaluation instrument (NOSE scale) [21]

MRD#					Date
Nasal obstruction symptoms evaluation scale
Over the past 1 month, how much of a problem were the following conditions for you? Please circle the most correct response
		Not a problem	Very mild problem	Moderate problem	Fairly bad problem	Severe problem
1.	Nasal congestion or stuffiness	0	1	2	3	4
2.	Nasal blockage or obstruction	0	1	2	3	4
3.	Trouble breathing through my nose	0	1	2	3	4
4.	Trouble sleeping	0	1	2	3	4
5.	Unable to get enough air through my nose during exercise or exertion	0	1	2	3	4

Nasal obstruction severity was also assessed subjectively, pre- and post-operatively using Visual Analogue Scale (VAS) [22], in which each patient rates his/her symptom severity from a score 0–10, where;

• 0 → no obstruction.

• 1–3 → mild obstruction.

• 4–7 → moderate obstruction.

• 8–10 → severe obstruction.

CO₂ laser turbinoplasty was performed under local anesthesia (10% xylocaine) and no postoperative nasal packing was needed. The mean operation time took 5 min/turbinate and no immediate complications (e.g., major bleeding) were observed. Spot ablation (8 W) of hypertrophic inferior turbinate was started anteriorly and continued posteriorly along the inferior border of the turbinate. Posterior most ends of the turbinate were completely ablated with the help of waveguides. Carbonization particles were removed at the end of the procedure with a moist cotton applicator in order to prevent foreign body reactions.

In the present study, Lund and Kennedy endoscopic scoring was used to evaluate grades of intranasal crusting and tissue healing (Table 3).

Table 3.

Lund and Kennedy endoscopic scoring for intranasal crusting & tissue healing [23]

For intranasal crusts 3-point classification system is used
0	Absence of crustations
1	Mild crustations, partially filling the nasal cavity
2	Severe crustations, fully filling the nasal cavity

For tissue healing 3-point classification system is used
Good healing	Rapid mucosal re-epithelization, minimal crustations, no nasal synechiae, patient feel relief of nasal symptoms
Moderate healing	Mucosal re-epithelization, mild to moderate crustations, with nasal synechiae, patient feel relief of nasal symptoms
Poor healing	Delayed mucosal re-epithelization, severe crustations and nasal synechiae, persistent inflammation and infection and patient doesn’t feel relief of his/her nasal symptoms

Postoperative intranasal pain [24–28] was analysed according to VAS by asking the patients to score the intranasal pain from 0 (none) to 10 (severe) (Table 4).

Table 4.

Visual analogue scale (VAS) for postoperative intranasal pain

Score	Strength of pain
0	No pain
1–3	Mild pain
4–6	Moderate pain
7–9	Severe pain
10	Excruciating pain

Observations and Results

The observations and results of this study were as follows (Fig. 1).

Fig. 1.

Age wise distribution of patients

Majority of patients belonged to age group between 16 to 30 years (50.94%) followed by age group between 31 and 45 years of age (20.75%) (Fig. 2).

Fig. 2.

Sex wise distribution of patients

Majority of patients who underwent laser surgery for hypertrophic inferior turbinates were males (67.92%) as compared to females which comprised 30.07% of the study population (Fig. 3).

Fig. 3.

Grades of inferior turbinate hypertrophy (ITH)

The above bar diagram shows the grades of inferior turbinate hypertrophy. Among the study population, 56% (30) patients had Grade 3 ITH, 32% (17) patients had Grade 4 ITH, 11.32% (06) patients had Grade 2 ITH while as none of the patients had Grade I ITH (0%) (Fig. 4 and Table 5).

Fig. 4.

Pre- and post-operative NOSE score in patients with inferior turbinate hypertrophy

Table 5.

Pre- and post-operative nasal obstruction symptom evaluation (NOSE) scores in patients with inferior turbinate hypertrophy

Parameter	Pre-operative scores	Post-operative scores			p value
		2 weeks	1 month	3 months
NOSE	64.90 (± 13.29)	18.96 (± 9.53)	9.81 (± 7.33)	5.09 (± 4.28)	0.02

The above table and bar diagram represent pre- and post-operative NOSE scores in patients with inferior turbinate hypertrophy at 2 weeks, 1 month and 3 months postoperatively. The pre-operative NOSE score was 64.90 (± 13.29) and post-operative NOSE score was 18.96 (± 9.53) at 2 weeks, 9.81 (± 7.33) at 1 month and 5.09 (± 4.28) at 3 months. The statistical difference was found to be significant with p value < 0.05 (Fig. 5 and Table 6).

Fig. 5.

Pre- and post-operative VAS score for nasal obstruction in patients with inferior turbinate hypertrophy

Table 6.

Pre- and post-operative visual analogue scale (VAS) scores for nasal obstruction in patients with inferior turbinate hypertrophy

Parameter	Pre-operative score (VAS)	Post-operative score (VAS)			p value
		2 weeks	1 month	3 months
Nasal obstruction	6.05 (± 2.1)	3.0 (± 1.01)	2.01 (± 0.90)	1.18 (± 0.40)	0.003

The above table and bar diagram represent pre- and post-operative visual analogue scale (VAS) score for nasal obstruction in patients with inferior turbinate hypertrophy at 2 weeks, 1 month and 3 months postoperatively. The pre-operative VAS score was 6.05 (± 2.1) and post-operative VAS score was 3.0 (± 1.01) at 2 weeks, 2.01 (± 0.90) at 1 month and 1.18 (± 0.40) at 3 months. The statistical difference was found to be significant with p value of (0.003) (Fig. 6).

Fig. 6.

Post-operative Lund & Kennedy endoscopic scoring for tissue healing at 2 weeks, 1 month and 3 months

The above bar diagram represents post-operative Lund & Kennedy endoscopic scoring for tissue healing. At 2-week follow-up, 79.24% of the patients showed good healing, 16.98% patients showed moderate healing and only 3.77% of patients showed poor healing. At 1-month follow-up, 96.22% of the patients demonstrated good healing and only 3.77% of the patients showed moderate healing. At 3 months follow-up all the patients demonstrated good healing (Fig. 7 and Table 7). The above bar diagram represents post-operative Lund & Kennedy endoscopic scoring for intranasal crusts. After 2 weeks of follow-up, 77.35% of patient's showed Grade 0, 15.09% patient's showed Grade 1 while as only 7.54% showed Grade 2 crusting. At 1 month and 3 months follow-up, 100% of patient's demonstrated Grade 0 crusting.

Fig. 7.

Post-operative Lund & Kennedy endoscopic scoring for intranasal crusts at 2 weeks, 1 month and 3 months

Table 7.

Post-operative visual analogue scale (VAS) scores for intranasal pain in patients with inferior turbinate hypertrophy

Score	No. of patients (n = 53)			Percentage (%)
	2 weeks	1 month	3 months	2 weeks	1 month	3 months
0 (no pain)	48	52	53	90.56	98.11	100
1–3 (mild pain)	4	1	0	7.54	1.88	0
4–6 (moderate pain)	1	0	0	1.88	0	0
7–9 (severe pain)	0	0	0	0	0	0
10 (excruciating pain)	0	0	0	0	0	0

The above table represents post-operative VAS scores for intranasal pain in patients with inferior turbinate hypertrophy. Out of 53 patients none of the patients complained of severe pain, 0 patients (7.54%) complained of mild pain and 01 patient (1.88%) complained of moderate pain at 2 weeks postoperatively. 01 patient (1.88%) complained of mild pain at 1-month follow-up. None of the patients complained of any pain at 3 months follow up.

Discussion

Nasal obstruction is one of the most frequent symptoms which an otorhinolaryngologist encounters. The CO₂ laser, which mainly cuts and ablates tissue, is used most often for vaporization of hypertrophied turbinates.

In the present study, male: female ratio of 2.1:1 with male predominance was observed and our finding is in concordance with that of a study done by Ramona Ungureanu et al. [29] which also showed male predominance. Majority of patients were seen in the age group of 16-30 years (50.94%) followed by age group 31–45 years (20.75%). Lippert et al. [30] conducted a study on 184 patients with average age of 36.3 ± 11.4 years. Sani et al. [31] in their study observed majority of patients to be in the age group of 21-30 years. Our findings are coinciding with that of both B. M. Lippert and A. Sani.

In the present study, VAS score changed from 6.05 (± 2.1) pre-operatively to 3.0 (± 1.01) at 2 weeks after procedure, 2.01 (± 0.90) at 1 month after procedure and 1.18 (± 0.40) at 3 months after the procedure. Similar results were noted by Ungureanu et al. [29] in their study which showed that the mean value of VAS for “nasal obstruction” parameter decreased from 7.86 before surgery to 4.4 one month after surgery and to 5.4 twelve months after surgery. Similar results were also observed by Prokopakis et al. [32] who noted a significant improvement in VAS scores for nasal obstruction postoperatively following CO₂ laser turbinoplasty.

In the present study, post-operative NOSE and VAS scale showed significant change (p < 0.05). NOSE score changed from 64.90 (± 13.29) pre-operatively to 18.96 (± 9.53) at 2 weeks after surgery, 9.81 (± 7.33) at 1 month after surgery and 5.09 (± 4.28) at 3 months after the procedure. There was little bleeding and no pain during or after the procedure. Similar conclusion was drawn by Kawamura et al. [11] who noted subjective improvement in 78% of cases at 1 month after surgery. Lippert et al. [30] retrospectively analysed data of surgeries done on one hundred and eighty-four patients with nasal obstruction due to hypertrophied inferior turbinates who were treated with the CO₂ laser. After a few days a positive effect was present. Six months after laser surgery, 87.5% had excellent or good results. After 1 year, 82.1% of the patients were satisfied, and after 2 years 80.4% were satisfied. Moreover, in 61.3% of the cases no further anti-allergic medication was necessary. This is in accordance with our study and the most frequent expression used by these patients to identify their improvement was “the bliss of being able to use their nose to breathe rather than their mouths”.

Sani et al. [31] also advocated use of CO₂ laser over submucosal diathermy in patients with inferior turbinate hypertrophy, after laser group reported a more significantly improved nasal airway (91% against 75%) and decreased rhinorrhoea (72.7% against 35%) when compared to the diathermy group.

In our study, postoperative pain was assessed using the visual analogue scale for pain at 2 weeks, 1 month and 3 months postoperatively. Out Of the 53 patients none of the patients complained of severe pain, 04 patients (7.54%) complained of mild pain and 01 patients (1.88%) complained of moderate pain at 2 weeks follow up. 01 patient (1.88%) complained of mild pain at 1 month after the procedure. None of the patients complained of pain at 3 months follow up. Similar conclusions were drawn by Lippert et al. [30] and Andrews Chakramakal et al. [33] who stated that CO₂ laser turbinoplasty was a relatively painless procedure.

Lund and Kennedy [23] endoscopic scoring for intranasal crusting was used to evaluate grades of crusting. We observed limited crusting on the surface of the turbinates where spotting was done and a mild edema with a more or less congested turbinate. In 41 patients (77.35%) no crusts were observed at 2 weeks post-operative period while as 8 patients (15.09%) had mild crusting and 4 patients (7.54%) had severe intranasal crusting. At subsequent follow-up of 1 month and 3 month all the patients were free of intranasal crusts indicating that the mucosal surface normalized within 3–4 weeks. In the present study, the healing quality was evaluated by Lund and Kennedy [23] endoscopic scoring at 2 weeks, 1 month and 3 months post-operatively and 42 patients (79.24%) showed good healing at 2 weeks, 09 patients (16.98%) showed moderate healing and 2 patients (3.77%) showed poor healing. 51 patients (96.22%) showed good healing at 1 month and all the 53 patients (100%) showed good healing at 3 months. This is in accordance with the study conducted by Bofares [34] who concluded that CO₂ laser turbinectomy can be considered as more preservative technique for nasal mucosa as well as the function of the nose as compared to submucosal diathermy technique. DeRowe et al. [35] also observed higher ablation rate and less circumferential damage to tissues with CO₂ laser. Lippert et al. [30] also noted minimal crusting postoperatively requiring less postoperative wound care.

CO₂ laser treatment of nasal obstruction due to hypertrophied inferior nasal turbinates can be performed as a minimally invasive procedure with satisfactory results. The advantage of a bloodless therapy in an outpatient treatment and satisfactory results compared with other surgical techniques that cause bleeding and require nasal packing and hospitalization favours this therapeutic modality.

Conclusion

To sum things up, CO₂ laser turbinoplasty is a safe and effective way of improving nasal flow. It offers more precision, gentleness, control and less intraoperative discomfort. It is a highly efficacious procedure for out-patient clinic-based inferior turbinate reduction with improvement in nasal airflow patency, reduced mouth breathing and less immediate postoperative pain, bleeding, crusting and no need of nasal packing. The favourable acceptance of CO₂ laser surgery may be attributed to its effectiveness on the one hand, and to the fact that the procedure is fast, involves little pain and can be done in an outpatient setting, on the other hand.

Thus, CO₂ laser turbinoplasty meets all of the criteria for an ideal method for the treatment of inferior turbinate hypertrophy with improvement of quality of life and reducing the risk of medical morbidity.

Funding

There has been no significant financial support for this work that could have influenced its outcome.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.