What is the role of surgery in the treatment of turbinate dysfunction?

Updated: Jun 24, 2021
  • Author: Sanford M Archer, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Surgical therapy is reserved for symptomatic patients with persistent hypertrophy of the turbinates who are not responding to medical management or in whom medical management is contraindicated. Because the function of the turbinates is important, care must be taken to avoid excessive resection and the resultant dry nose syndrome (ozena).

The most important decision-making factor in the surgical management of the symptomatic patient with enlarged turbinates is whether the hypertrophy is bony, mucosal, or a combination of both. If bony hypertrophy is present, then some form of resection is necessary, either by way of an actual trimming of the bone and mucosa or through submucosal resection of the turbinate bone. [1] Submucosal resection of the inferior turbinate preserves most of the mucosa and allows for preservation of function. This technique is less likely to cause atrophic rhinitis when performed properly. Turbinate trim allows for resection of the turbinate through both the bone and mucosa. If excessive mucosa is resected, prolonged healing and mild-to-moderate nasal dryness may occur postoperatively.

More options are available for the care of the patient with turbinate dysfunction that is due entirely to mucosal hypertrophy. Every physical treatment imaginable has been tried on the turbinate mucosa at one time or another. Because no single superior technique is clearly available, the experience of the surgeon and the intraoperative findings play the greatest role in the choice of techniques.

Physical injury to the mucosa consists of cryosurgery (cold), thermal ablation (heat), or radiofrequency ablation. Both cryosurgery and radiofrequency ablation require special and costly equipment. Superficial thermal ablation can be performed with a laser or cautery unit. Intramural ablation can be preformed with a cautery unit or with a radiofrequency device. [8] Phenol application to the turbinate mucosa has been used in the past but is no longer used because of toxicity issues. Trimming the excessive mucosa is also very effective for the management of turbinate hypertrophy. Care must be taken to not be overly aggressive in the amount of mucosa removed for the previously stated reasons.

A newer technique using a very small (2 mm) microdebrider blade through a small stab incision shows great promise in reducing the size of the inferior turbinates without requiring external physical injury to the mucosal membranes. This technique also shows excellent long-term results compared with diathermy and radiofrequency ablation. [9] See the video below.

A stab incision is made at the anterior head of the inferior turbinate. Blunt dissection beneath the mucoperiosteum elevates tissue for subsequent microdebridement. The microdebrider is turned in all directions, but mucosa is entirely preserved. Video courtesy of Vijay R Ramakrishnan, MD.

A randomized, double-blind study by Barham et al found that medial flap turbinoplasty had better outcomes in inferior turbinate reduction than did submucosal electrocautery and submucosal powered turbinate reduction. At 5-year follow-up, decongestants were being used only occasionally or not at all in 90.2% of the turbinoplasty nasal cavities, compared with 15.8% and 37.8% of the cavities that underwent electrocautery and submucosal powered turbinate procedures, respectively. Moreover, just 12% of the turbinoplasty cavities required a revision procedure, versus 54% and 40% of the electrocautery and submucosal powered turbinate procedure cavities, respectively. [10]

In a study of pediatric patients with chronic nasal congestion, Whelan et al found that inferior turbinate reduction resulted in symptom improvement. The investigators reported that the median sum score from the Nasal Obstruction Symptom Evaluation (NOSE) survey dropped from 65 points out of 100 preoperatively to 20 points at the end of the first postoperative year. While a median of one medication was taken preoperatively, postoperatively that fell to zero. However, patients with allergic rhinitis had a significantly higher 12-month postoperative NOSE score than did those without the condition. [11]


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