The Journal of Laryngology and Otology March 1990, Vol. 104, pp. 206-209
Inferior turbinectomy: Comparison of four techniques SAMY ELWANY,
M.D.,*
ROBERT HARRISON,
M.D.**
Abstract As yet, there is no totally satisfactory means for treating hypertrophied turbinates and the proper management of turbinate dysfunction remains in question. In the present series, four of the widely practiced surgical procedures for the reduction of the size of the inferior turbinates were evaluated and compared. In all cases turbinectomy was performed as an isolated procedure. Eighty patients with chronic non-allergic rhinitis and hypertrophied inferior turbinates were selected, randomly divided into four groups, and followed up post-operatively for one year. Study of the results indicated that the beneficial effect of the operation is mainly mechanical by reduction of the resistance to nasal airflow. The post-operative improvement in smell acuity correlated positively with the increased patency of the nasal airway. None of the procedures had a deleterious effect on olfactory acuity. In contrast, the operation failed to enhance the mucociliary clearance rate or significantly decrease nasal drainage. Partial inferior turbinectomy and laser turbinectomy improved nasal breathing in 77 per cent of patients, and enhanced olfactory acuity in 78 per cent of patients who had pre-operative hyposmia. The results of turbinoplasty and cryoturbinectomy were less favourable. The surgical technique, advantages, and drawbacks of each of these procedures are discussed.
from the study. The patients were randomly divided into four groups (Table I) by assigning the first qualified patient to the first group, the second patient to the second group and so on. Inclusion of 20 patients in each group was done to ensure reliable results and statistical tests should the latter be necessary. Another 10 normal subjects without present or past history of chronic nasal diseases served as control for the mucociliary and olfactory studies. Ethical approval was obtained from the Local Director of Medical Education and Research, and all participants gave written, informed consents.
Introduction The inferior turbinates are responsible for nasal obstruction more often than is commonly thought (Goode, 1977). A long list of treatment regimens has been suggested to deal with their hypertrophy and dysfunction (Donald, 1973); these have included several intranasal and systemic medicaments: submucosal injection of sclerosants or corticosteroids (Goode, 1977); cryoturbinectomy (Ozenberger, 1973; Moore and Bicknell, 1980; Bumsted, 1984); resection of all (Moore et al., 1985; Ophir et al., 1985) or part (Goode, 1977; Saunders, 1982) of the inferior turbinates, turbinoplasty or submucosal resection of the inferior turbinate bone (House, 1951; Goode, 1977) and laser turbinectomy (Selkin, 1985; Fukutake etal., 1988). This study was designed to compare the efficacy of four of the widely practiced turbinectomy procedures. The comparison entailed clinical data, mucociliary studies and olfactory tests. Rhinomanometery was not performed since there are several doubts as to its practical relevance (Mygind, 1980).
Pre-operative evaluation The pre-operative evaluation included a complete history and clinical examination. All patients were examined with a flexible nasopharyngoscope to determine the full extent of nasal obstruction. Radiographic and cytologic examination of nasal smears were routinely performed. Mucociliary clearance velocity and olfactory thresholds were then measured and patients were requested to stop local and systemic medications three days before carrying out these tests.
Material and Methods The study included 80 patients with nasal obstruction due to non-allergic rhinitis and hypertrophied inferior turbinates. All patients were refractory to conservative treatment. The patients were 53 males and 27 females and they were aged 24-46 years (mean age, 30.6 years). Patients with other major nasal diseases were excluded
Measurement of mucociliary clearance Mucociliary clearance rate was measured using radiopaque Teflon discs 1-2 mm in diameter. The technique, validity, and safety of this method have been previously
'Assistant Professor, Alexandria Medical School, Alexandria, Egypt; Consultant Otolaryngologist, Dr Fakhry Hospital, Alkhobar, Saudi Arabia. """Consultant Otolaryngologist, Medical Center, Saudi Arabia. Accepted for publication 6 January 1990. 206
207
INFERIOR TURBINECTOMY: COMPARISON OF FOUR TECHNIQUES
TABLE I PATIENT'S GROUPS AND PREOPERATIVE DATA
Symptoms (No.) Group I II III IV
Operation PIT IT CT LT
Mean age (yr) 33 30.5 28 31.5
Nasal obstruction
Nasal obstruction
Hyposmia
20 20 20 20
12 11 10 11
10 8 9 9
PIT=Partial Inferior turbinectomy IT=Inferior turbinoplasty CT=Cryoturbinectomy LT=Laser turbinectomy
described (Yergen et ai, 1978; Elwany and Mekhamer, 1987). Olfactory assessment Olfactory threshold determination was conducted in odourless room under standard conditions. The odorants used were eugenol and citral diluted in diethyl phthalate. The highest concentration was a 1:2 (v/v) solution of the pure odorant. Serial solutions of the odorants were prepared. Thresholds were tested by a three-way forced-choice sniff technique (Henkin and Bartter, 1966) using ascending series of concentrations. The threshold was defined as the number of the dilution steps of the lowest concentration for which three consecutive correct identifications were made. When no threshold could be determined, a value of zero was assigned. The patients were not informed about the number of odorants used, or were they given feedbacks on their tests. Surgical technique All procedures were performed under local anaesthesia with the patient supine and the head elevated. The patients were given sedative drugs intravenously. Partial Inferior Turbinectomy (PIT) Angled scissors were used, one blade was inserted beneath the inferior turbinate and the other on top of it, so that the resection included the turbinate mucosa and bone. The extent of the resection depended upon the degree of the hypertrophy. Inferior Turbinoplasty (IT) A curved incision was made on the anterior and inferior edges of the turbinate and carried down to the bone. The mucosa was elevated off the bone as far back as possible and the bone was removed with a biting forceps. Cryoturbinectomy (CT) Cryoturbinectomy was performed using the SpemblyAmoils BMS-40 nitrous oxide cryosurgery unit. The cryoprobe was applied first to the medial then to the lateral surfaces of the turbinate. The temperature was quickly lowered to —85°C, and each surface was frozen for 75 seconds.
Laser Turbinectomy (LT) A carbon dioxide laser and a self-retaining speculum were used. The laser was sighted through a Zeiss OPM1-1 surgical microscope. Turbinectomy was performed by vaporizing the anterior portion and the inferior border as far posteriorly as possible. The lateral surface was not vaporized. Vaporization was done by the defocused laser beam at 20-30 W for one minute. Post-operative evaluation a. Post-operative headache and discomfort All patients were interviewed 12 hours post-postoperatively and their responses were graded on a 0-3 scale (Elwany et al, 1986): 0 = No discomfort or headache. 1 = Moderate discomfort or headache, no analgesics used. 2 = Moderate headache needing non-narcotic analgesics. 3 = Severe headache needing narcotic analgesics. b. Post-operative follow-up All patients were examined weekly for one month, and every two months for a year. At the end of the first post-operative year, all patients were evaluated via nasal examination and a patient questionnaire. The patency of the nasal airway was graded on a 0-3 scale as follows: 0 = nasal breathing became worse. 1 = No change. 2 = Little improvement. 3 = Significant improvement. Finally, the mucociliary and olfactory tests were repeated. During the post-opertive period, none of the patients was kept on permanent drug therapy, and all patients were requested to stop all medications three days before testing. The students t test was used for statistical analysis, and a P value
Inferior turbinectomy: Comparison of four techniques SAMY ELWANY,
M.D.,*
ROBERT HARRISON,
M.D.**
Abstract As yet, there is no totally satisfactory means for treating hypertrophied turbinates and the proper management of turbinate dysfunction remains in question. In the present series, four of the widely practiced surgical procedures for the reduction of the size of the inferior turbinates were evaluated and compared. In all cases turbinectomy was performed as an isolated procedure. Eighty patients with chronic non-allergic rhinitis and hypertrophied inferior turbinates were selected, randomly divided into four groups, and followed up post-operatively for one year. Study of the results indicated that the beneficial effect of the operation is mainly mechanical by reduction of the resistance to nasal airflow. The post-operative improvement in smell acuity correlated positively with the increased patency of the nasal airway. None of the procedures had a deleterious effect on olfactory acuity. In contrast, the operation failed to enhance the mucociliary clearance rate or significantly decrease nasal drainage. Partial inferior turbinectomy and laser turbinectomy improved nasal breathing in 77 per cent of patients, and enhanced olfactory acuity in 78 per cent of patients who had pre-operative hyposmia. The results of turbinoplasty and cryoturbinectomy were less favourable. The surgical technique, advantages, and drawbacks of each of these procedures are discussed.
from the study. The patients were randomly divided into four groups (Table I) by assigning the first qualified patient to the first group, the second patient to the second group and so on. Inclusion of 20 patients in each group was done to ensure reliable results and statistical tests should the latter be necessary. Another 10 normal subjects without present or past history of chronic nasal diseases served as control for the mucociliary and olfactory studies. Ethical approval was obtained from the Local Director of Medical Education and Research, and all participants gave written, informed consents.
Introduction The inferior turbinates are responsible for nasal obstruction more often than is commonly thought (Goode, 1977). A long list of treatment regimens has been suggested to deal with their hypertrophy and dysfunction (Donald, 1973); these have included several intranasal and systemic medicaments: submucosal injection of sclerosants or corticosteroids (Goode, 1977); cryoturbinectomy (Ozenberger, 1973; Moore and Bicknell, 1980; Bumsted, 1984); resection of all (Moore et al., 1985; Ophir et al., 1985) or part (Goode, 1977; Saunders, 1982) of the inferior turbinates, turbinoplasty or submucosal resection of the inferior turbinate bone (House, 1951; Goode, 1977) and laser turbinectomy (Selkin, 1985; Fukutake etal., 1988). This study was designed to compare the efficacy of four of the widely practiced turbinectomy procedures. The comparison entailed clinical data, mucociliary studies and olfactory tests. Rhinomanometery was not performed since there are several doubts as to its practical relevance (Mygind, 1980).
Pre-operative evaluation The pre-operative evaluation included a complete history and clinical examination. All patients were examined with a flexible nasopharyngoscope to determine the full extent of nasal obstruction. Radiographic and cytologic examination of nasal smears were routinely performed. Mucociliary clearance velocity and olfactory thresholds were then measured and patients were requested to stop local and systemic medications three days before carrying out these tests.
Material and Methods The study included 80 patients with nasal obstruction due to non-allergic rhinitis and hypertrophied inferior turbinates. All patients were refractory to conservative treatment. The patients were 53 males and 27 females and they were aged 24-46 years (mean age, 30.6 years). Patients with other major nasal diseases were excluded
Measurement of mucociliary clearance Mucociliary clearance rate was measured using radiopaque Teflon discs 1-2 mm in diameter. The technique, validity, and safety of this method have been previously
'Assistant Professor, Alexandria Medical School, Alexandria, Egypt; Consultant Otolaryngologist, Dr Fakhry Hospital, Alkhobar, Saudi Arabia. """Consultant Otolaryngologist, Medical Center, Saudi Arabia. Accepted for publication 6 January 1990. 206
207
INFERIOR TURBINECTOMY: COMPARISON OF FOUR TECHNIQUES
TABLE I PATIENT'S GROUPS AND PREOPERATIVE DATA
Symptoms (No.) Group I II III IV
Operation PIT IT CT LT
Mean age (yr) 33 30.5 28 31.5
Nasal obstruction
Nasal obstruction
Hyposmia
20 20 20 20
12 11 10 11
10 8 9 9
PIT=Partial Inferior turbinectomy IT=Inferior turbinoplasty CT=Cryoturbinectomy LT=Laser turbinectomy
described (Yergen et ai, 1978; Elwany and Mekhamer, 1987). Olfactory assessment Olfactory threshold determination was conducted in odourless room under standard conditions. The odorants used were eugenol and citral diluted in diethyl phthalate. The highest concentration was a 1:2 (v/v) solution of the pure odorant. Serial solutions of the odorants were prepared. Thresholds were tested by a three-way forced-choice sniff technique (Henkin and Bartter, 1966) using ascending series of concentrations. The threshold was defined as the number of the dilution steps of the lowest concentration for which three consecutive correct identifications were made. When no threshold could be determined, a value of zero was assigned. The patients were not informed about the number of odorants used, or were they given feedbacks on their tests. Surgical technique All procedures were performed under local anaesthesia with the patient supine and the head elevated. The patients were given sedative drugs intravenously. Partial Inferior Turbinectomy (PIT) Angled scissors were used, one blade was inserted beneath the inferior turbinate and the other on top of it, so that the resection included the turbinate mucosa and bone. The extent of the resection depended upon the degree of the hypertrophy. Inferior Turbinoplasty (IT) A curved incision was made on the anterior and inferior edges of the turbinate and carried down to the bone. The mucosa was elevated off the bone as far back as possible and the bone was removed with a biting forceps. Cryoturbinectomy (CT) Cryoturbinectomy was performed using the SpemblyAmoils BMS-40 nitrous oxide cryosurgery unit. The cryoprobe was applied first to the medial then to the lateral surfaces of the turbinate. The temperature was quickly lowered to —85°C, and each surface was frozen for 75 seconds.
Laser Turbinectomy (LT) A carbon dioxide laser and a self-retaining speculum were used. The laser was sighted through a Zeiss OPM1-1 surgical microscope. Turbinectomy was performed by vaporizing the anterior portion and the inferior border as far posteriorly as possible. The lateral surface was not vaporized. Vaporization was done by the defocused laser beam at 20-30 W for one minute. Post-operative evaluation a. Post-operative headache and discomfort All patients were interviewed 12 hours post-postoperatively and their responses were graded on a 0-3 scale (Elwany et al, 1986): 0 = No discomfort or headache. 1 = Moderate discomfort or headache, no analgesics used. 2 = Moderate headache needing non-narcotic analgesics. 3 = Severe headache needing narcotic analgesics. b. Post-operative follow-up All patients were examined weekly for one month, and every two months for a year. At the end of the first post-operative year, all patients were evaluated via nasal examination and a patient questionnaire. The patency of the nasal airway was graded on a 0-3 scale as follows: 0 = nasal breathing became worse. 1 = No change. 2 = Little improvement. 3 = Significant improvement. Finally, the mucociliary and olfactory tests were repeated. During the post-opertive period, none of the patients was kept on permanent drug therapy, and all patients were requested to stop all medications three days before testing. The students t test was used for statistical analysis, and a P value
