Radiofrequency tissue reduction for turbinate hypertrophy

# Recommendations
This document replaces previous guidance on radiofrequency tissue reduction for turbinate hypertrophy (interventional procedure guidance 36).
Current evidence on the safety of radiofrequency tissue reduction for turbinate hypertrophy is adequate. Evidence on efficacy in the short and medium term (to about 2 years) is also adequate. Therefore this procedure may be used with normal arrangements for clinical governance, consent and audit.
During the consent process patients should be informed about alternative treatment options. They should be warned about the risk of recurrence of symptoms and the possible need for further treatments.# Indications and current treatments
Inferior turbinates are ridges inside the nose, covered by mucous membrane, which increase the surface area within the nose and help to filter and humidify inspired air. Inflammation of the mucous membrane (rhinitis) can cause inferior turbinates to swell (turbinate hypertrophy). This narrows the nasal passage, and may cause complete nasal obstruction. Symptoms include breathing difficulties, excessive mucous secretion (rhinorrhoea), postnasal drip, facial discomfort or pain and mid-facial headaches.
Treatment options depend on the duration and severity of turbinate hypertrophy. Medical treatments include corticosteroid injections, nasal corticosteroid sprays and decongestants. Surgical treatments include microdebrider-assisted turbinoplasty and laser-assisted turbinoplasty. These procedures are reserved for patients with persistent symptomatic turbinate hypertrophy that has not responded to medical management, or for patients in whom medical management is contraindicated.# The procedure
Radiofrequency tissue reduction (radiofrequency-assisted inferior turbinoplasty) aims to reduce the size of inferior turbinates that are inflamed because of vasomotor or allergic rhinitis.
Radiofrequency tissue reduction is usually performed using local anaesthesia in an outpatient setting. A radiofrequency probe is inserted submucosally at the anterior end of the inferior turbinate and is advanced to its posterior end. Radiofrequency energy is applied for a number of seconds to the anterior, middle and posterior third of each inferior turbinate, heating the submucosal tissue around the probe and causing coagulation. Small blood vessels responsible for the enlargement of the turbinate are also ablated during the procedure, limiting their ability to swell and expand. The submucosal tissue shrinks during healing, thereby reducing excess tissue volume.# Efficacy
This section describes efficacy outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.
In a randomised controlled trial of 120 patients treated by radiofrequency or microdebrider-assisted turbinoplasty, mean visual analogue scale scores (ranging from 1 to 10, with lower scores indicating better outcomes) for nasal obstruction, sneezing, rhinorrhoea and snoring improved from 8.5 to 1.5, 6.0 to 1.8, 6.6 to 1.7 and 6.6 to 1.6 respectively in the radiofrequency group at 6month follow-up (p values <0.05). In the microdebrider group, mean visual analogue scale scores for nasal obstruction, sneezing, rhinorrhoea and snoring improved from 8.7 to 1.4, 6.2 to 1.7, 7.0 to 1.6 and 6.7 to 1.6 respectively (p values <0.05). No statistically significant differences in visual analogue scale scores were observed between the 2 treatments at 6month follow-up. At 3year follow-up, mean visual analogue scale scores for nasal obstruction, sneezing, rhinorrhoea and snoring were 8.3, 5.6, 6.5 and 6.2 in the radiofrequency group and 1.6, 1.9, 1.7 and 1.8 respectively in the microdebrider group. All inter-group comparison p values were <0.05.
In a randomised controlled trial of 50 patients treated by radiofrequency-assisted turbinoplasty or traditional surgery, mean scores for endoscopic evaluations of turbinate oedema (scores ranged from 0 to 4 with lower scores indicating better outcomes) decreased from 2.6 to 0.6 and from 2.5 to 0.6 respectively at 3month follow-up (p values for changes within groups <0.05; no inter-group comparison p value was reported). Mean scores for endoscopic evaluations of turbinate secretions decreased from 1.7 to 0.6 in the radiofrequency-assisted turbinoplasty group and from 1.7 to 0.5 in the traditional surgery group at 3month follow-up (p values for changes within groups <0.05; no inter-group comparison p value was reported).
In the randomised controlled trial of 120 patients treated by radiofrequency or microdebrider-assisted turbinoplasty, mean total nasal resistance measurements (using 75 Pa as the reference point) improved from 0.31 to 0.15 Pa/ml/s (p<0.05) and from 0.32 to 0.15 Pa/ml/s (p<0.05) respectively at 6month follow-up (inter-group comparison p value not significant). At 3year follow-up, mean total nasal resistance measurements in the radiofrequency and microdebrider-assisted turbinoplasty groups were 0.31 and 0.16 Pa/ml/s respectively (p<0.05).
In a case series of 197 patients treated by radiofrequency-assisted turbinoplasty, mean volumes of the region extending from the nostril to 5 cm within the nasal cavity increased from 5.55 cm3 at baseline to 10.56 cm3 at 5year follow-up (p<0.05).
Specialist advisers listed key efficacy outcomes as subjective improvements of the nasal airway assessed by validated questionnaires such as the Sino-Nasal Outcome Test.# Safety
This section describes safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.
Crusting was reported in 6% (10/158) of patients in a case series of 158 patients (time of occurrence not reported). In the same study, rhinorrhoea, bleeding, soreness, increased nasal obstruction and impaired olfactory sense were reported in 3% (5/158), 2% (3/158), 1% (2/158), 1% (2/158) and 1% (1/158) of patients respectively (time of occurrence not reported).
Mucosal oedema was reported in 70% (14/20) of patients in the radiofrequency-assisted turbinoplasty group in a randomised controlled trial of 80 patients treated by radiofrequency-assisted turbinoplasty, high-frequency diathermy, electrocauterisation or partial inferior turbinotomy at 2month follow-up (occurrence in other groups not reported).
A case report described a patient with an arteriovenous haemangioma at the site of radiofrequency ablation, diagnosed 1 year after the procedure. The author suggested that thermal damage by the radiofrequency probe, post-surgical oedema of the nasal mucosa or an asymptomatic infection at the surgical site might have induced angiogenesis leading to the formation of the arteriovenous haemangioma.
A case report described a patient with de novo intractable post-nasal drip, caused by perforation of the mucosa in the posterior part of an inferior turbinate by the radiofrequency probe.
Specialist advisers listed theoretical adverse events as bleeding from the turbinates leading to epistaxis, swelling (oedema) leading to worsening nasal obstruction, intranasal adhesions, crusting and atrophy of nasal mucosa.# Further information
This guidance is a review of 'Radiofrequency volumetric tissue reduction for turbinate hypertrophy' NICE interventional procedure guidance 36 (2004).
For related NICE guidance see the NICE website.

# Information for patients
NICE has produced information on this procedure for patients and carers (Information for the public). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedures guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS.
This guidance was developed using the NICE interventional procedures guidance process.
It updates and replaces NICE interventional procedure guidance 36.
We have produced a summary of this guidance for patients and carers. Information about the evidence the guidance is based on is also available.
NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services.  We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland.  Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.
Your responsibility
    This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
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     National Institute for Health and Care Excellence 2014. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
ISBN 978-1-4731-0619-2