Auris' Nasus' Larynx (Tokyo) 17, 87-93 (1990)

CRYOSURGERY OF THE INFERIOR NASAL TURBINATESl Edgar CHIOSSONE, M. D.,* Jose R. GUTIERREZ, M. D.,** and Juan L. EMMANUELLI, M. D.***

* Venezuelan

Foundation of Otology, Caracas, Venezuela ** Department of Otolaryngology, Carlos Arvelo Hospital, Caracas, Venezuela *** Department of Otolaryngology, Domingo Luciani Hospital, Caracas, Venezuela

Forty-seven patients with irreversible nasal obstruction due to inferior turbinate hypertrophy were treated by cryosurgery, the short and medium term results having been clinically evaluated. Permanent good results in nasal breathing were achieved in 83 % of the patients. Failures are mostly related to turbinates hypertrophy due to nasal allergy. The combination of cryosurgery and nasal septoplasty, in cases of hypertrophy associated with deformities of nasal septum, gives an excellent result. Cryosurgery of hypertrophic nasal turbinates is a simple, safe, and reliable procedure to improve nasal breathing in cases of nasal turbinate hypertrophy. Nasal obstruction is a common distressing symptom which is often the reason for otolaryngological consultation. There are multiple etiological factors which may lead to a periodical or permanent nasal obstruction and also multiplies the therapeutic procedures which have been suggested to relieve or eradicate it in a temporary or definite way. The potentiality of cryosurgery to reduce the volume of hypertrophic tissues has been proposed as a therapeutic choice to reduce the size of the hypertrophic inferior turbinates to increase the inner nasal spaces. Cryotherapy for destruction of dermatological lesions is an old procedure which has been used since the early sixties for the treatment of head and neck tumors (COOPER, 1963; MILLER, 1969). In 1970, OZEMBERGER reported the results obtained in treating chronic rhiReceived for publication December 25, 1989 Read at the X Annual Meeting of the American College of Cryosurgery, Margarita, Venezuela, June 21-24, 1989. 1

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nitis by cryosurgery. He used an equipment specially designed for intranasal work with cryoprobes adapted to easy turbinate applications and Freon as freezing gas. Later he presented better results with more sophisticated equipment and nitrous oxide as a freezing agent (OZEMBERGER, 1973). Recent modifications of cryoprobes for more efficient freezing of inferior turbinates are bringing still more improvement to the procedure and enhancing better results (WILLIAMSON, TIMMS, and CENTAY, 1988). Beside the good results obtained by cryosurgery of turbinates, good results have also been reported in the treatment of vasomotor rhinitis with cryosurgery (HOLDEN, 1972; KARJA, JOKINEN, and PALVA, 1975; BUMSTED, 1984). Cells destruction by freezing is fundamentally based in intracellular ice crystals formation and in the denaturalization of proteins. Crystallization leads to cellular membrane destruction and rising of electrolytic concentration to reach toxic levels. Thrombosis occurs in the small blood vessels and local ischemia increases the tissue destruction. There is also an immunological reaction producing antibodies against the necrotic tissue which help their elimination (KARJA et al., 1975). The destruction of parasympathetic noradrenergic nerves by the freezing effect decreases the vasomotor reaction (LUNDBLAD, BRODIN, LUNDBERG, and ANGGARD, 1985), which can be beneficial in allergic rhinitis. The purpose of this presentation is to analyze our short and medium term results in the treatment by cryosurgery of inferior nasal turbinate hypertrophy in 47 patients. MATERIALS AND METHODS

Sixty-two cryosurgical procedures to reduce the size of hypertrophic inferior nasal turbinates were performed between 1984 and 1988. Of these 62 procedures, an adequate follow up was possible in 47 patients, the remaining 15 patients being excluded for this clinical survey. For evaluation of postoperative results, a questionnaire was prepared to be answered by the patients, most of them were approached personally (see ApPENDIX). From the 47 selected patients, 31 were male and 16 female with a minimum age of 10 years and a maximum of 66 years, mean age of 27.5 years. The cryosurgical procedure was mainly performed to improve nasal obstruction due to irreversible hypertrophy of inferior nasal turbinates. This clinical finding was present in all the patients but the great majority of them (70 %) had other secondary diagnosis such as nasal allergy (46 %), deviated nasal septum (23 %), and in smaller percentage, vasomotor rhinitis, rhinitis medicamentosa, and chronic sinusitis. The majority of these patients had been conservatively treated previously with local and oral vasoconstrictors, antihistaminics, and topical and systemic corticosteroids, without any substantial improvement. In some patients with nasal septum deviation, cryosurgery was performed as an initial

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procedure to avoid a nasal septoplasty, but in other cases, cryosurgery was a complement to this intranasal surgery. Cryosurgery was performed by means of a cryosurgical Frigitronics ™ unit, model T-82, using nitrous oxide for freezing as low as -70°C, with a flat gold cryoprobe protected by Teflon to assure a maximum contact area and to protect the surrounding tissues from freezing (Fig. I). The nasal cavity is sprayed with a 0.05 % oximetazoline chloride solution to achieve maximum shrinking of the nasal mucosa and with a IO % Lidocaine spray for topical anesthesia. Two milliliters of a 2 % Lidocaine HCI solution with I X 100,000 epinephrine are injected in the whole body of the inferior turbinate and, after a IO min waiting to allow a good anesthetic diffusion, the cryoprobe is applied along the inferior border of the inferior turbinate during 60 s at a sub-freezing temperature of - 70°C. The procedure is repeated in the same way in the upper surface of the turbinate (Fig. 2). It is advisable to administer per os a non narcotic analgesic 1 h prior to the procedure to increase the pain threshold and minimize the discomfort which is unavoidable in the great majority of cases due to the spreading of cold temperatures to the non anesthetized surrounding tissues. This

Fig. 1. Flat gold cryoprobe for maximun contact with the turbinate surface, covered by Teflon to protect the surrounding tissues from freezing.

Fig. 2. Frontal schema of nasal section showing the correct cryoprobe application to upper and lower inferior turbinates surfaces.

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pain is transitory and can be controlled with an additional administration of analgesic drugs after the procedure. It is seldom necessary to administer analgesics in the days following cryosurgery since the freezing necrosis is painless. The use of a topical nasal vasoconstrictor is indicated to alleviate the severe nasal obstruction due to edema and postoperative necrosis. Systemic antibiotics are only indicated if clear signs of local infection appear. In the fifth postoperative day, the sphacelous on top of the turbinate is removed with a forceps or light suction. The turbinate surface should be at this time somewhat reddish and edematous but smooth and without any ulceration. Postoperative follow up controls are performed 2 weeks and one-and-a-half month later. RESULTS

Figure 3 summarizes the results. From the 47 patients who had cryosurgery of the inferior nasal turbinates, 39 (83 %) had a substantial improvement in nasal breathing. One patient (2 %) had only a slight improvement and 7 (15 %) had no benefit. From the 39 improved group, 35 (90 %) maintained a permanent improvement during the postoperative observation period (up to 4 years), and 4 patients had a recurrent nasal obstruction. Three of them had a significant nasal allergy and one had a severe rhinitis medicamentosa. Figure 4 shows the influence of simultaneous pathology associated with inferior nasal turbinates in the postoperative results of nasal cryosurgery. In 14 patients with pure turbinate hypertrophy, without any other associate diagnosis, only one had no improvement in the nasal obstruction. In 24 patients, turbinate hypertrophy was clearly related to nasal allergy. Five of them had no improvement at all; and in the remaining 18 there was a very good immediate result, but, in a medium term evaluation, 3 of them had recurrence of their nasal obstruction. In another group of 12 patients with turbinate hypertrophy associated with a significant nasal septum deviation, all but one had a substantial permanent relief

TOTAL IMPROVEMENT 39 83%

WITHOUT IMPROVEMENT 7 15%

IMPROVEMENT 1 2% Fig. 3. Cryosurgery of nasal turbinates: General results.

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TURBINATE HYPERT. T.H.+ N . ALLERGY T.H.+ SEPTAL DEVIAT. T.H.+ OTHER PATOL.

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RESULTS ANAUSIS

Fig. 4.

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Cryosurgery of nasal turbinates: Results analysis.

of symptoms. In 7 of the 12 patients with additional diagnosis of significant nasal septum deviation, a nasal septoplasty was performed beside the cryosurgery of the inferior turbinates. A very good result in correcting nasal obstruction was achieved in 100 % of these cases. Nasal cryosurgery was in general well tolerated by patients. Eleven of them (23 %) reported some discomfort and local pain during the procedure. Moderate pain in the nose irradiated to the frontal region persisted in a few patients up to 24 h after the procedure. No major complications or sequelae were observed in this group. COMMENTS

Medium term follow up in the 47 patients whom nasal cryosurgery was performed revealed that in 83 % of them a good permanent improvement in nasal obstruction was achieved. It can be considered as a satisfactory result taking into consideration that, in the majority of cases, an associate nasal pathology was also present which, in variable degrees, couldbe.tesponsible for symptoms. Only 15 %of the cases did not have any benefit from the procedure. The improvement in nasal breathing seems to be permanent since 35 patients (90 %), of the 39 initially improved group, maintained the good results in a longer observation period. Recurrences are mostly related to the type of nasal pathology which produces the nasal turbinate hypertrophy, specially in nasal allergy cases, A fact present, in various degrees, in 75 % of the patients involved in this study. When the turbinate hypertrophy is pure and not related to any other nasal pathology, the cryosurgery result is excellent with permanent improvement in 93 % of cases. This is the result of the effective reduction in size of large inferior

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turbinates which produce nasal obstruction. When a significant septal deviation is also associated with the turbinate hypertrophy, the cryosurgical result is also excellent, providing that the surgical correction of the septal deviation is also performed. This can be done before or after cryosurgery, with a few months interval, to prevent intranasal adhesions. Ninety-two percent of our patients with these two diagnosis permanently improved their nasal obstruction and in 100 % of the cases in which nasal septoplasty complemented cryosurgery, the results were very good and permanent. When inferior nasal turbinate hypertrophy is related to nasal allergy, results are not as good as in other associated conditions. If the total failure cases are analyzed, in 71 % of them nasal allergy was present; however, substantial improvement was achieved in many cases with associated nasal allergy. It may be due to the benefit of cryosurgery in cases of vasomotor rhinitis as described by BUMSTED (1984).

The moderate pain and discomfort, easily controlled by symptomatic medication, cannot be considered as a complication. The fact that no major complications with nasal cryosurgery have been reported, makes the procedure a safe and simple one. CONCLUSIONS

Based on the results obtained in this study we come to the following conclusions: 1) Cryosurgery is an excellent and reliable procedure for the treatment of nasal obstruction due to hypertrophy of inferior nasal turbinates associated or not with other intranasal pathology. 2) When cryosurgery of turbinates is performed associated with nasal septoplasty in cases of significant septal deviation, an excellent and permanent improvement in nasal breathing is expected. 3) Nasal allergy has been considered as a limiting factor in achieving a good permanent long-term improvement of nasal obstruction treated by cryosurgery. However, good results can be achieved in many cases of turbinate hypertrophy related to nasal allergy, due to the success in controlling of vasomotor rhinitis. 4) Medium term follow up controls show a permanent good result throughout the years in the majority of cases. However, it is necessary to observe this same group of patients for at least five more years to substantiate this statement. 5) Nasal cryosurgery is a simple and safe procedure free of major complications when performed by experienced hands.

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REFERENCES BUMSTED, R. M.: Cryotherapy for chronic vasomotor rhinitis: Technique and patient selection for improved results. Laryngoscope 94: 539-544, 1984. COOPER, 1. S.: A New method of destruction or extirpation of benign or malignant tumors. N. Engl. J. Med. 268: 743-749, 1963. LUNDBLAD, L., BRODIN, E., LUNDBERG, J. M., and ANGGARD, A.: Effects of nasal capsaicin pretreatment and cryosurgery on sneezing reflexes, neurogenic plasma extravasation, sensory and sympathetic neurons. Acta Otolaryngol. 100: 117-127, 1985. HOLDEN, H. B.: Cryosurgery in E. N. T. practice. J. Laryngol. Otol. 86: 821-827, 1972. KARJA, J., JOKINEN, K., and PALVA, A.: Experience with cryotherapy in otolaryngological practice. J. Laryngol. Otol. 89: 519-526, 1975. MILLER, D.: Three years experience with cryosurgery in head and neck tumors. Ann. Otol. Rhinol. Laryngol. 78: 786-791, 1969. OZEMBERGER, J. M.: Cryosurgery in chronic rhinitis. Laryngoscope 80: 723-734, 1970. OZEMBERGER, J. M.: Cryosurgery for the treatment of chronic rhinitis. Laryngoscope 83: 508-516, 1973. PRINCIPATO, J. J.: A 15 years retrospective of chronic rhinitis and cryosurgery. Ear Nose Throat J. 65: 22-28, 1986. WILLIAMSON, I. G., TIMMS, M., and CENTAY, P.: A new cryoprobe with advantages in turbinate freezing. J. Laryngol. Otol. 102: 503-505, 1988.

APPENDIX QUESTIONNAIRE 1.

2. 3. 4.

5. 6.

7. 8.

a) Did cryosurgery improve your nasal obstruction? Yes No __ b) Did it become worse after cryosurgery? Yes__ No __ How was the improvement? Total__ Partial __ How long did it last? Years__ Months__ Permanently __ a) Were you taking medication before cryosurgery? Yes __ No __ Which _ __ b) Are you taking it now? Yes__ No __ c) If you do, has the dosage been: Increased__ Decreased__ Same __ Have other symptoms improved beside nasal obstruction? Yes__ No __ Did you experienced discomfort with the procedure? Yes__ No __ If you did, was it: Slight__ Moderate__ Severe __ Forhowlong._ _ _ _ ___ Did you suffer any complication? Yes__ No__ In the affirmative, describe them _ _ _ _ _ _ __ How do you consider the procedure? Good Fair__ Poor__

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Cryosurgery of the inferior nasal turbinates.

Forty-seven patients with irreversible nasal obstruction due to inferior turbinate hypertrophy were treated by cryosurgery, the short and medium term ...
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