Turbinate Reduction Procedures

Techniques For Reduce The Size of Inferior Turbinates

Turbinate Reduction Procedures

Some terminological information

Before starting the article, I would like to share some terminological information:

The growth of nasal turbinates (turbinate hypertrophy) is a condition in which the meats inside the nose become larger than normal and cause nasal congestion.

The lower turbinate (inferior turbinate) is the turbinate at the bottom of the nasal cavity. Generally, reduction operations are performed for this turbinate.

Nasal hyperventilation, turbinate resections, which have recently been brought to the fore, may cause loss of permanent nasal function and is not a recommended method!

Abnormal reduction of the turbinate of the nose or an increase in the rate of intranasal airflow, such as in patients with holes in the nasal septum, and associated symptoms such as dryness of the nose, crusting of the nose and feeling of air hunger.

Empty nose syndrome, which occurs when partial or complete removal of the turbinate of the nose, loss of nasal functions, dryness in the nose, crusting, the emergence of painful areas, a dark sticky epidemic in the post nasal-area can be seen.

Atrophic rhinitis is the inflammation of the nasal mucosa, which is infected by long-term structural changes and dryness. It can be mild or severe depending on the amount of symptoms, and acute or chronic depending on the duration of symptoms.

The nasolacrimal duct is the tear duct that opens into the nose.

Epiphora is the condition of tear flowing out due to obstruction of tear duct for various reasons.

The out fracture of the turbinates (lateralization of the turbinate, fracture of the nasal turbinate bone to the outside) is the process of fracturing the nasal bone with the aid of a metal tool, especially in patients with enlargement of the conical turbinate.

About nasal turbinates and their duties

Turbinate Reduction Procedures

There are 3 pieces of nasal turbinate, namely turbinates, in each nasal cavity. Nasal turbinates performs the tasks of changing the direction of air flow entering the nose, heating, humidifying and pressurizing the air. In particular, the lower nose meats, ie lower turbinates, are responsible for most of these tasks. In the case of enlarging of the lower nasal turbinates for various reasons, ie allergies, infection, genetic predisposition and the growth of nasal meats due to different reasons, narrowing of the airway in the nose and the introduction of insufficient air may cause very different symptoms such as nasal congestion, open mouth sleep, and decrease in blood oxygen levels. It can rise up. Medical procedures can be planned to reduce the amount of nasal turbinates when enough nasal meats are not reduced. So, in this article, I wanted to summarize the procedures used for the reduction of the nasal turbinates in patients whose medical treatment did not provide sufficient shrinkage of the their volumes.

Turbinate reduction techniques and procedures

Partial or total turbinate resections

Partial or total turbinate resections

Partial or total turbinate resections have been described by Holmes in 1890 and 1900, and their efficacy has been reported in different studies, but studies suggesting that surgical removal or reduction of the gums may cause dryness and atrophic rhinitis in the long term. This technique, which was abandoned and made very rarely, was re-modified in the 1970s and started to be used. Nasal congestion is effective in removing the nasal congestion, but if the surgical removal of excessive amounts of nose in the nose permanently abnormal air gap (abnormally large airway area within the nose) will occur in patients such as nasal hyperventilation, empty nose syndrome, atrophic rhinitis, nasal dryness may occur. . In partial turbinate resections, the anterior portion of the lower turbinate can be simply cut with scissors after being held with a clamp. Sometimes the turbinate can be displaced at the same time.
Total turbinate resections can cause loss of permanent nasal function and are not recommended!
In total nasal turbinate resections, the lower turbinate is laterally lateralized and then removed by a sharp dissection. The remaining turbinate is burned with monopolar cautery or bipolar cautery to control bleeding. However, the current methods aim to preserve the anatomy of the turbinates, that is, the nasal turbinate as much as possible, and protect the mucosa, and turbinate resections are not recommended.
Risks of total turbinate resection
Apart from the risk of impaired physiology in the nose, the lateral nasal branch of the sphenopalatine artery feeding to the inferior turbinate may be injured during total resection. Complications such as crusting, delayed recovery, unpleasant nasal odor may occur in the early period after this procedure. In total resection, the site of involuntary nasolacrimal canal may be damaged, and in the long term, scar tissue may obstruct the nasolacrimal canal into the nasal opening and may present as a complication of the epiphora. Complications such as dryness, crusting, atrophic rhinitis and adhesion may occur in the late period due to the decrease in the volume of the nasal mucosa surface. In the long term, due to abnormal air gap in the long-term, the heating and purification of the incoming air is impaired, and the symptoms of empty nasal syndrome, such as lack of air in the nose, air dryness in the nose, dryness in the nasal region, emergence of painful spots in the nose may occur. Partial turbinate resections can be used, but total turbinate resections are not recommended today.
Turbinate resection with microdebrider
Turbinate resection with microdebrider became widespread after the use of the microdebrider instrument in orthopedic surgery before the 1990s, followed by endoscopic sinus surgery. The procedure can be performed under general or local anesthesia. After the local anesthetic containing adrenaline and lidocaine is injected into the lower turbinate, incision is made to the end of the lower turbinate with the number 15 scalpel and dissection is performed over the bone. After the tunnel is prepared, care is taken not to damage the mucosa and the microdebrider is placed in this tunnel. First, the bone turbinate surface is then shaved under the direct view of the tunnel until the submucosa tissue is brought to the desired thickness. After the procedure, minimal bleeding is stopped by cauterization into the mucosa. After the procedure, the turbinates in the nose may break out (out fracture).

In this process, preservation of the mucosa integrity of the lower turbinates, ie, is one of the advantages of the process. The protection of both the mucosal and bone components of the nasal turbinate provides protection of this function unit of the nose. This is one of the most important advantages of the process. After the procedure, crusting remains minimal and recovery is quick, but if the tissue is removed with the use of microdebrider, ie submucosa and bone tissue are removed too much, the nasal turbinate may become much smaller than normal and abnormal accelerated air flow may occur in the nose. The main objective is to remove as little tissue as possible.

Outward fracture of the bone turbinate (turbinate outfracture - turbinate lateralization)

With the turbinate out fracture, the bone turbinate section (bone part of the nasal turbinate), which takes place in the nose, can be broken with the help of a metal tool after the local anesthetic injection, and the nasal turbinate can be crushed to the outside. During the procedure, a long-ended nose speculum or elevators may be used. Since mucosal integrity is maintained, it is not very useful for nasal obstruction of mucosal hypertrophy. In cases of bone turbinate hypertrophy, the volume of the airway is gain because the turbinate body will be directed outwards. The risk of complications is negligible. Complications such as crusting and hemorrhage are usually not seen, since there is no need for tampons after the procedure, as the integrity of the mucosa is slightly impaired. This can be done with electrocauterization, carbon dioxide laser and microdebrider turbin resection.

Submucosal turbinate resection

Submucous turbinate resection is performed in cases where bone turbinate hypertrophy is occluded intranasal passage. What is done during this procedure is not a definition that fills the meaning of "submucous turbinate resection" for the lower turbinates. Although right-handed surgeons are more difficult to perform in the right lower turbinate during this surgery, although they usually use curved scissors during resection, even undesirable turbinate parts may involve the inclusion of mucosal areas. During dissection after dissection, some turbinate mucosa may also be involved, which subtracts submucous resection from its true meaning. Atrophic rhinitis complication may be high in this method which was popularized by House in 1970s. The procedure can be performed under general or local anesthesia. A vertical incision is made with a scalpel 15 at the tip of the turbinate and the posterior elevation continues in the submucosal plane with the aid of a knife or elevator. The bone is placed in the turbinate and resected by disc from front to back. After the procedure, bleeding can be stopped by cauterization. Care should be taken to avoid mucosal tears during the procedure. Mucosal tears may cause adhesions within the nose, ie synechia. Unintentionally excessive mucosa removal during surgery may cause necrosis of the bone turbinate. As a result, crusting and bone necrosis may occur after recovery.

Inferior turbinoplasty

The purpose of this procedure is to maintain the integrity of the mucosa and resect the bone turbinate. It is aimed to preserve mucosal integrity, prevent complications related to mucosal damage, and to eliminate nasal obstruction by resection of bone turbinate. The procedure can be performed under local and general anesthesia. In bone turbinate hypertrophies, impaired blood function and preservation of the mucosa may reduce complications.

Lower turbinate radiofrequency (lower turbinate ablation with radiofrequency)

This technique, first applied by Dr.Li et al. In 1998, has now become the most commonly used technique for nose reduction in the world. Turbinate radiofrequency energy is applied submucosally by means of a special electrode and an ionic reaction at the cell level generated by this energy results in local heat increase. Thus, thermal damage occurs in the submucosal area of ​​the skin without damaging the surface of the turbinates. During recovery, secondary fibrosis is triggered and wound contraction results in tissue volume reduction. In addition, heat damage causes cell destruction by evoperation and causes atrophy in submucosal secretory cells. In this way, it causes regression of symptoms, especially in patients with allergic rhinitis and vasomotor rhinitis. In other words, secretion in the nose provides a decrease in production. The radiofrequency devices used here have also been modernized in recent years, ie automatic devices that measure tissue resistance and cut energy by self-calculating without carbonization without too much damage to the tissue. In case of an uncontrolled amount of energy with nasal turbinate radiofrequency with old type radiofrequency devices, necrosis of the nasal turbinates, severe tissue changes, loss of volume in the nasal turbinate due to thermal damages may occur and irreversible tissue damage occurs. Therefore, there is the possibility of empty nasal syndrome, atrophic rhinitis, nasal crusting and infections. It is appropriate to treat only the sub-mucosal tissue with a limited amount of radiofrequency energy without making as much as possible. The procedure can be performed under local or general anesthesia. After a small amount of local anesthetic injection, the probe of the radiofrequency device is inserted into the turbinate of the nose and the button of the device is applied to radiofrequency. After the procedure, the device is stopped by radio frequency to the entrance hole of the probe is stopped because it reduces mucosal damage is more practical than other procedures, is a method that is less likely to complicate and is used frequently in mucosal hypertrophies, has no effect on the growth of bone turbinate.

Plasma coagulation with argon laser

Argon plasma coagulation is a high frequency electrocautery technique. This high frequency electrocautery technique transmits the electric current through ionized argon gas without tissue contact. The energy beam is transmitted to the tissue with a repulsive force from the probe tip and tissue damage is achieved. The procedure can be performed under office conditions under local topical anesthesia. Postoperative tamponade is not always necessary. The risk of bleeding is less, as compared to carbon dioxide laser, there is a cavitation and devitalization immediately following application in the tissue and a secondary contraction. At the same time epithelization following submucosal minimal fibrosis occurs.

Reduction of nasal turbinate by laser

In 1977, the first Dr. Laser turbinate ablation, which has been tried by Lenz et al. On patients with vasomotor rhinitis, can now be performed in different ways. Laser ablation is performed with yag laser and KTP laser; In the last 10 years, carbon dioxide laser has been widely used. Atrophy and allergic rhinitis and regression of some vasomotor rhinitis symptoms may occur in submucosal secretory cells due to thermal energy generated under the mucosa by carbon dioxide laser method. Laser cases should be selected very well. One of the most important points to note here is that patients have more mucosal hypertrophy. Otherwise, the volume gain due to mucosal ablation is minimal. Atrophy of the secreting glands can be achieved by creating thermal energy in the mucosa with carbon dioxide laser. It is thought that energy does not go deeper than 1 millimeter in the mucosa with carbon dioxide laser. The most important advantage compared to other surgical methods is that the risk of bleeding is minimal and postoperative tamponade is not required. Postoperative edema is less, but crusting in the nose in the early period during recovery may disturb the patient. Nd: Yag laser and KTP lasers have a deeper effect on the mucosa and can cause problems such as abnormal volume loss in the mucosa.

Reduction of nasal turbinate with cryotherapy

In cryotherapy, the cryo tips are placed in the turbinate and frozen in the mucosa using liquid nitrogen or nitrous oxide. Intracellular ice crystals cause denaturation of nuclear and cell membrane proteins, cell membrane damage occurs as a result of tissue ischemia and tissue necrosis. The aim is to reduce mucosal thickness and atrophy submucosal secretory cells. It can be performed under local anesthesia under office conditions. The concave probe is contacted with the mucosal surface and heat is applied at -40 to 80 degrees Celsius for at least 30 seconds. The mucosa is frozen. During the application, care should be taken not to contact the tip of the cryo device with the septum, vestibular area and columella. Postoperative crusting and edema may occur. Tissue necrosis occurs for a longer period of time and results are more pronounced after 6 weeks. Especially in patients with vasomotor and allergic rhinitis.

Reduction of nasal turbinate with electrocoagulation

In electrocoagulation technique, electrical energy can be applied directly to the mucosa and into the turbinate by bipolar or monopolar way. In this way, treatment can be provided in mucosal hypertrophies. The aim is to thin the mucosa and remove the nasal congestion. Following local topical anesthesia, energy is transferred to the mucosa by touching the tip of the aspirated cautery or bipolar cautery on the hypertrophic mucosa. Side effects such as crusting and delayed recovery may occur after the procedure. Because mucosa damage is more. Another use of the electrocautery is the application of electrical energy into the turbinate in the direction from front to back with a needle-tipped monopolar cautery that follows anesthesia. An energy of 25 watts can be applied for approximately 30 seconds. Risk of undesirable burns, tissue necrosis and bone infections may occur. Modern radio frequency devices are much more advantageous than electrocauters. Among the advantages of electrocautical turbinate reduction technique is the decrease in the risk of bleeding, the need for postoperative tamponade, and the ability to perform in office conditions. There are conflicting publications on the long-term results of turbinate ablation with electrocautery. In patients with allergic rhinitis and vasomotor rhinitis, long-term complaints were unchanged. Today, the use of new technologies such as radiofrequency and laser is limited.

Vidian neurectomy

The sympathetic and parasympathetic nerve fibers of the inferior turbinate of the vidian neurectomy are carried by the sphenopalatine ganglion vidian nerve. Vidian neurectomy also cuts by finding the vidian nerve in the pteriopalatine fossa and postganglionic parasympathetic fibers and sympathetic fibers leading to the nose are disabled. This procedure is indicated in cases of vasomotor rhinitis, allergic rhinitis, chronic epiphora and senile rhinorrhea. The aim is to reduce intranasal secretions. It is not a direct nasal flesh process. The procedure was first described in 1961 by Goldman Wood for vasomotor rhinitis. The transantral and transnasal route is cut with the presence of the vidian nerve in the pteriopalatine fossa. Its use is limited in patients with turbinate hypertrophy.

Videos about turbinate hypertropy and nasal turbinate reduction:

Radiofrequency Turbinate Reduction Video - 1

Radiofrequency Turbinate Reduction Video - 2

Radiofrequency Turbinate Reduction Video - 3

Similar links >> Turbinate Hypertrophy - Definition, Symptoms, Causes and Treatment / Why Turbinates Are Important? - Empty Nose Syndrome / Why Turbinates Regrow / Hypertrophied Again After Radiofrequency Volume Reduction?

Source links >> Turbinate Reduction / Coding for RFA of the Turbinates | American Academy of ... / Nasal Airway Obstruction, An Issue of Otolaryngologic ...

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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