Which inferior turbinate reduction technique best decreases nasal obstruction? (2013)

Chronic nasal obstruction can significantly impair patients' quality of life and is a frequent complaint seen by otolaryngologists. Inferior turbinate hypertrophy is a common cause of chronic nasal obstruction. Various etiologies for the hypertrophy of inferior turbinates include allergic reactions, nonallergic rhinitis, chronic hypertrophic rhinitis, and compensatory hypertrophy as seen in septal deviation. Conservative medical treatment options include topical decongestants and corticosteroids, antihistamines, systemic decongestants, mast cell stabilizers, and immunotherapy. However, in patients who have failed medical management, surgical reduction of the inferior turbinates is an effective treatment. Many surgical techniques exist to reduce the size of the inferior turbinates. Conventional surgical options include partial or total turbinectomy, turbinoplasty, electrocautery, cryotherapy, laser cautery, submucosal resection, and submucosal resection with lateral displacement. Newer techniques include radiofrequency-assisted turbinoplasty, microdebrider-assisted turbinoplasty, and ultrasound turbinate reduction. There is no consensus as to which surgical technique is most effective in decreasing nasal obstruction. Passali et al.1 performed a prospective randomized trial of long-term efficacy (6 year follow-up) of six surgical techniques for inferior turbinate hypertrophy (turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateral displacement). They randomized 382 patients into the various surgical procedures. After 6 years, only the submucosal resection groups had continued nasal patency, and the addition of lateral displacement of the inferior turbinate improved the long-term results. These authors recommended submucosal resection combined with lateral displacement as the first-choice technique for treating nasal obstruction due to inferior turbinate hypertrophy. Conventional surgical interventions can be associated with postoperative bleeding, crusting, pain, nasal dryness, foul odor, synechia, and change in olfaction. The U.S. Food and Drug Administration approved radiofrequency volumetric tissue reduction for the treatment of airway obstruction in 1998. After its approval, investigators reported use of radiofrequency volumetric tissue reduction as an alternative to traditional surgical methods to treat turbinate hypertrophy. During the radiofrequency turbinate reduction surgery, radiofrequency energy is delivered submucosally in the inferior turbinate via a needle on a handheld device, with resultant tissue ablation by heat desiccation created by frictional energy. The submucosal necrosis is replaced by fibroblasts during normal healing, with wound contraction leading to reduction in turbinate volume. Temperatures range from 60° to 90° C in radiofrequency, whereas they can reach 800° C with electrocautery or laser techniques. The radiofrequency method preserves the turbinate mucosa, whereas the mucosal injury that can occur during electrocautery and surgical resection is associated with postoperative crusting. In 2004, Nease and Krempl2 published a prospective, randomized, single-blinded, placebo-controlled trial of 32 patients to determine the short-term efficacy of radiofrequency treatment of inferior turbinate hypertrophy. Patients were randomized to either a treatment or a placebo arm. The placebo operation included all of the surgical steps in the treatment group; however, no energy was delivered through the active tip of the handpiece. In their study, they determined that after 6 months there was improvement in frequency of obstruction, severity of obstruction, and overall ability to breathe in the treatment group. This was the first randomized trial to show that radiofrequency treatment of inferior turbinate hypertrophy is more effective than placebo in decreasing nasal obstruction. Microdebrider-assisted inferior turbinoplasty was introduced in the late 1990s and is another mucosa-preservation technique. The microdebrider provides suction, with the ability to precisely resect inferior turbinate tissue. Liu et al.3 and Cingi et al.,4 in 2009 and 2010 respectively, each conducted prospective randomized trials comparing microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty. In the Liu study, 120 patients were randomized to either microdebrider-assisted or radiofrequency-assisted inferior turbinoplasty, with a 3-year postoperative follow-up. While both groups showed improvement in nasal obstructive symptoms at 6 months; only the microdebrider group showed continued results after 2 years. The Cingi study enrolled 268 patients and evaluated the short-term degree of nasal obstruction in patients up to 3 months postoperatively. They found that both the microdebrider and radiofrequency group had statistically significant improvement in nasal obstruction symptoms after 1 month; however, only the microdebrider group persisted with statistically significant improvement at 3 months. Therefore, both the Liu and Cingi studies showed that microdebrider-assisted turbinoplasty was more effective than the radiofrequency-assisted technique for the relief of nasal obstructive symptoms. The use of ultrasound treatment of hypertrophied inferior turbinates has only been investigated by Gindros et al.,5 a group from Greece. Ultrasound use in rhinology is new, with little documentation in the literature. The ultrasound technique involves advancing a low-frequency ultrasonic nasal probe submucosally in the inferior turbinate and advancing along its length. For 10 seconds an anterior-posterior movement is performed, and then the probe is withdrawn from the turbinate. In 2010 Gindros et al.5 published a prospective randomized trial comparing ultrasound turbinate reduction, radiofrequency ablation, and traditional submucosal cauterization. Subjective evaluations by patients were obtained up to 6 months postoperatively. The most dramatic results were seen with the ultrasound procedure, followed by the radiofrequency ablation. There was no significant difference in results between the radiofrequency and electrocautery group. Of conventional inferior turbinate reduction techniques, submucosal resection combined with lateral displacement is the most effective at decreasing nasal obstruction caused by inferior turbinate hypertrophy. In the turbinoplasty group, based on the current evidence, microdebrider-assisted and ultrasound turbinate reduction have been shown to be the most effective. A prospective randomized trial comparing the microdebrider-assisted and ultrasound turbinate reduction has not yet been performed. Little research exists on the ultrasound procedure; thus, the microdebrider-assisted turbinate reduction technique has the advantage of more widespread familiarity. All five of the studies reviewed are level 1 evidence (prospective, randomized trials). Most of the current studies only compare two surgical techniques for inferior turbinate reduction. Therefore, no surgical technique for inferior turbinate reduction has been proven to be the best at reducing symptoms of nasal obstruction.