Keywords
turbinate hypertrophy - turbinates - turbinoplasty - nasal obstruction - piezoelectric
Lack of consensus and mixed results are the most striking features when reviewing
the existing literature concerning treatment of inferior turbinate hypertrophy (ITH).[1]
[2]
[3]
[4]
[5]
[6] This is mostly due to the shortage of perspective, large number, studies with inadequate
long-term follow-up, combined with the fact that multiple variables, which cannot
be easily evaluated separately, are at play both intraoperatively and in functional
assessment postoperatively. A wide variety of medical and surgical alternatives, alone
or combined, thus exist in the treatment of ITH, without their efficacy being either
measured or proven. Surgical techniques differ markedly regarding tissue excision
or preservation. This leads to uncertainty not only on the treatment of turbinate
hypertrophy per se, but also on how to treat hypertrophic turbinates in the common
setting of a rhinoseptoplasty where hypertrophy of the contralateral turbinate to
the concave side of the deviated septum is treated together with septoplasty. Some
facts, however, are generally agreed upon especially in the recent literature:
-
There is general concert on the rationale to combine septoplasty with turbinoplasty
when treating septal deviation. This is done both to reduce hypertrophy of the contralateral
turbinate, which expands and “curls” around the deviation, as well as to allow enough
space for the septum to be repositioned in the midline[2]
[7]
[8]
[9]
-
It is well known that both mucosal and bone hypertrophy usually coexist in turbinate
hypertrophy. This leads to the frequent combination of procedures that treat both
mucosa and bone in combination.[2]
[10]
-
There seems to be consensus on the fact that bone matters more, especially in compensatory
hypertrophy of the inferior turbinate.[11]
[12]
-
Most studies concur on the fact that lateralization, which implies bone out-fracturing
rather than bone removal, is effective and that its results can be durable,[13]
[14]
[15]
[16]
[17] although some disagree on the long-term outcome.[6] Such efficacy seems increased when combined with other treatments addressed to mucosal
hypertrophy.[3]
[7]
[13]
[17]
[18]
[19] Significantly, submucosal resection combined with lateralization results seem to
provide excellent results long-term.[20]
[21]
-
A common complication of turbinoplasty is intraoperative and postoperative bleeding.[1]
[6] Thus, techniques that reduce bleeding should be preferred. Submucosal turbinate
resection may cause bleeding.
Considering all the above, it would stand to reason that the ideal method for ITH
would be one that aims to prevent bleeding, is fast to perform and implies bone fracturing
and lateralization, as well as coexisting treatment of the hypertrophic mucosa.
Relevant Anatomy
Most studies highlight the importance of bony as well as mucosal contribution to ITH.[2]
[10] A prevalence of bone versus mucosa enlargement has been demonstrated by several
authors.[10]
[11]
[12] Patients with septal deviation have compensatory ITH which is mainly due to the
expansion of the bone rather than the mucosa.[10]
[12]
The usual shape of the turbinate bone is uncinate, with the bone projecting from the
lateral nasal bony wall at an acute angle. Understanding the blood supply of the inferior
turbinate is important regarding its relationship to potential bleeding: the sphenopalatine
artery, after exiting from its foramen on the lateral nasal wall, becomes the posterior
lateral nasal artery which ends up into the two main inferior turbinate and middle
turbinate branches. Importantly, the inferior turbinate branch generally runs in close
relation to the bone of the inferior turbinate medially, until it ends on the anterior
part of the turbinate while still maintaining its relatively large diameter Although
anatomical variations exist and a further contribution to the inferior turbinate branch
of the sphenopalatine artery may originate from the descending palatine artery, it
is important to note that in the vast majority of specimens of most studies the relatively
large branches which supply the inferior turbinate enter the turbinate posteriorly
and then run medially, adherent to the bone or travelling in a canal within the bone.[22]
[23]
[24]
The close relationship between the inferior turbinate branch and the turbinate bone
well explains why bone resection/trimming during turbinate reduction may lead to even
considerable bleeding. Most peri- and postoperative problems that occur while treating
ITH are indeed related to hemorrhage, hence the obvious merits of a method which will
prevent such occurrence.
Cone-beam Analysis
A computed tomography (CT) scan is a well-recognized, objective, non–operator-dependent,
method of assessing turbinate hypertrophy before surgery. Although several studies
have also used CT for postoperative evaluation of results,[8]
[12]
[13]
[14]
[15]
[25]
[26] for instance, following outfracture procedures, it remains difficult to justify
a routine execution of the procedure postoperatively in clinical practice.
As well as defining dimensions, a CT scan can also discriminate and accurately measure
the bone versus mucosa component of the inferior turbinate. A definite further advantage
is the use of the cone-beam CT scan (CBCT), as favored extensively by the senior author
over the last years in his rhinoplasty practice. CBCT is still unfamiliar to most
surgeons performing rhinoplasty, both plastic surgeons and otolaryngologists, while
it is better known in the dental and maxillofacial community, where it finds, for
instance, uniform applications for treatment, planning, and diagnosis in implant dentistry.[27]
[28] With a quantity of delivered radiation about the seventh part of a conventional
CT scan CBCT is a user-friendly, quick technique which can be extrapolated with many
advantages to rhinoplasty planning.
What CBCT can easily do is to essentially provide a useful roadmap to surgery regarding
the following: studying septum deformities and deviations; studying the nasal bones
regarding their shape, symmetry, and thickness; assessing the thickness of the skin;
and demonstrating the length and shape of the bony cap together with the underlying
extension of the upper laterals. Although outside the scope of this article (and object
of a forthcoming publication by the senior author), it has to be noted that CBCT in
rhinoseptoplasty has the great advantage of allowing viewing the axial coronal and
sagittal planes at once, running and scrolling all three in parallel, as well as providing
a striking quality of three-dimensional (3D) imaging. Different setups in 3D reconstruction
permit to highlight progressively bone versus soft tissue, thus demonstrating contour
details and irregularities as connected to the underlying bone. CBCT, like any CT
scan, is also easily employed to study both the middle turbinate, regarding the presence
and shape of concha bullosa, as well as the inferior turbinate regarding its measurable
volume and percentage of bone versus mucosa. This is obviously an element that may
guide the decision for turbinoplasty with or without fracturing the uncinate bone.
CBCT, as compared with the conventional CT, causes the patient no inconvenience (is
done standing in a few minutes) and has very few if any drawbacks, these being minimal
radiation and a very limited cost.
Surgical Technique (see [Video 1])
Surgical Technique (see [Video 1])
Video 1
The video shows a three-dimensional representation built on the cone-beam CT images
and the step-by-step turbinoplasty surgical technique.
Analysis. The decision for turbinoplasty is based primarily on clinical examination and CBCT
scan. Although factors contributing to functional deficiency in each patient are multiple
and it is not easy to define the specific contribution of each, the usual setting
is one of a deviated septum with contralateral turbinate enlargement. Preoperatively,
all patients undergo a CBCT scan. As well as being a roadmap to many elements relevant
to rhinoseptoplasty as noted earlier, the CBCT will allow dimensional assessment of
an enlarged turbinate, demonstrate compensatory hypertrophy in deviated septum, and
show the percentage of bone versus mucosa.
Anesthesia. All patients are operated under general hypotensive anesthesia with endotracheal
intubation. Turbinoplasty is never performed per se in the senior author's practice,
but only as an adjunct to a rhinoseptoplasty, consistently done by the open approach.
Generally, after completing the septoplasty by in situ or extracorporeal technique,
if necessary, infiltration of the inferior turbinate is done from anterior to posterior
with 1% lidocaine with 1 to 100,000 epinephrine administered by a dental Carpule syringe.
Incision and Limited Tunneling at Bony Edge
Turbinoplasty is usually performed by the senior author following completion of dorsal
maneuvers, including hump reduction, osteoplasty, and osteotomies. Septoplasty can
be done before or after, depending on the circumstances: doing it before safeguards the septum from any accidental dislodgement during turbinoplasty, while
doing it after is simpler because of the additional space gained on either side of the septum. Essentially,
it depends on the complexity of the septoplasty.
A full-thickness incision measuring 5 to 8 mm through the anterior-inferior surface
of the turbinate is made by a fine angled Microsurgical needle (E1651—Covidien Valleylab)
in the cutting mode. The incision has just to be long enough to allow passage for
the small elevator first, and then the insert to follow. Once the Bovie tip touches
bone, it is withdrawn and a short tunnel is made between the mucosa and the inferior
turbinate bone, by the use of a small sharp elevator (Micro Elevator 190–268, Marina
Medical, Florida). This tunnel only extends a few millimeters distal to the bony edge.
Piezo Osteotomy
Next, the elevator is withdrawn and a long, angled or straight, piezo insert (UniVR 03600008 [[Fig. 1a]] or MT9–13 03600016 [[Fig. 1b]]; Mectron) is carefully inserted into the tunnel. It doesn't much matter whether
the insert is angled or straight, while the appropriate length matters. Essentially,
the same insert used in other portions of the rhinoplasty is re-employed. This is
either the same insert used by the senior author in most rhinoplasties for low to
low osteotomies (angled: UniVR), or the insert used for posterior septoplasty and
resection of vomerine deviations (straight: MT9–13).
Fig. 1 The two piezo inserts usually employed (a) angled UniVR and (b) straight MT9–13.
The insert is then activated and moved in a direction from caudal to cephalic, essentially
close to and perpendicular to the line of attachment of the turbinate bone to the
lateral nasal wall, which is in fact the site of maximum angulation as shown in [Fig. 2a,b]. This is different and distinct from the line of conventional (manual) outfracture,
which occurs more laterally, along the weakest point of the bone ([Fig. 3]). One will usually feel initial bone resistance and then a clear give as the bone
is entirely cut by the piezo insert where it angles. It is striking to note that at
this point the inferior turbinate easily lateralizes passively, actually almost spontaneously.
Occasionally, a proper break at the desired point doesn't happen, and one has to persist
in finding further paths of bone resection by pushing the insert on a different trajectory,
until the same result of “breaking a hinge,” sometimes in more than one spot, is obtained.
The bone is thus piecemealed, however, with an equally effective outcome.
Fig. 2 Three-dimensional rendering of the right inferior turbinate bone illustrating the
piezo cut line. (a) Anterior view. (b) Posterior view.
Fig. 3 Three-dimensional rendering of the inferior turbinate bone showing the line of the
conventional outfracture along the weakest part of the bone (red dots).
Submucosal Needle Microcauterization
Next, the same Bovie tip cautery is introduced, submucosally along its full length,
prevalently in the inferomedial portion of the turbinate. Coagulation current is used
while the needle is withdrawn progressively, thus achieving a submucosal intraturbinal
electric microcauterization which works with a “thermage” effect to reduce the soft
tissue volume by fibrosis without the direct damage caused by surface electrocautery.
Three or four passes are usually made.
Finishing Maneuvers
Once the steps mentioned before are completed, large Mayo scissors are introduced,
placed flat on the turbinate, and used to complete lateralization of the turbinate.
Some bleeding at the site of the initial full thickness incision is frequent and the
edges are cauterized by bipolar cautery. No suturing is necessary. A Merocell sponge
(Medtronic Inc.) is then inserted between turbinate and septum. When expanded, it
will oppose any tendency to further bleeding by compression.
After the remaining tip portion of the rhinoplasty is completed and the incisions
are closed, Doyle splints are routinely employed. A Vaseline gauze, impregnated with
Bactroban ointment (GlaxoSmithKline plc.) is also routinely inserted between the Doyle
splint and the turbinate on either side. In addition to splinting the septum, Doyle
splints may also serve to help maintain the achieved lateralization of the inferior
turbinates. The duration of the whole turbinoplasty is usually of two or three minutes
for each turbinate. This is negligible, especially when compared with the three hours
of standard duration of a primary rhinoseptoplasty.
Clinical Series and Results
Clinical Series and Results
In this article, we present a case series of 157 consecutive patients, all operated
in the same venue in a private setting by the senior author for rhinoseptoplasty concomitant
with turbinoplasty using the technique described earlier, over a full year between
February 2018 and February 2019. The study was conducted according to the declaration
of Helsinki for biomedical research of human subjects. In no instance was turbinoplasty
performed as a separate maneuver. Eighty-nine patients were females and 68 males,
with age range from 16 to 73 years; 105 patients (67%) were primaries and 52 (33%)
secondaries, with this designation generally indicating revision cases operated once
or more previously, most frequently requiring rib grafting. This case series obviously
excluded a minority of patients operated for rhinoseptoplasty over the same time span
in which no turbinoplasty was performed (some secondaries where aggressive turbinectomy
had been previously performed or the rare primaries with very small turbinates).
All patients underwent CT scan preoperatively, usually CBCT, save for those that had
had a conventional CT already done. Criteria for turbinoplasty were multiple:
-
Preoperative functional issue (reported breathing difficulty) as confirmed on clinical
examination and CT-CBCT.
-
Concurrent correction of deviated septum with controlateral turbinate enlargement.
-
Prophylaxis, where a reduction of airway volume was anticipated.
It has to be noted that a low threshold was employed in deciding on turbinoplasty.
Even in those patients who reported breathing satisfactorily preoperatively, turbinoplasty
was usually performed “prophylactically” when narrowing and lowering of the bony vault
was planned, unless the turbinates were especially small, in presence or absence of
septal deviation.
All patients were seen between 3 to 6 and 9 to 12 months, within the postoperative
visit related to rhinoseptoplasty. For those in the latter part of the study, follow-up
was obviously limited between 9 to 6 and 3 months. Most patients complied with all
their planned follow-up. Eleven patients did not return following the first follow-up
at 3 months.
Postoperative outcomes pertinent to the study addressed breathing function, clinical
examination, and assessment of complications.
Breathing function improvement was measured by a brief questionnaire, which was essentially a patient-reported
outcome measure comparing preoperative with postoperative status. The simple question
on postoperative check was “is your breathing improved, same, or worse?” Judging the
efficacy by patient-reported outcome and perception of effectiveness may seem subjective,
but it is a known fact that quantitative measurements of airflow do not necessarily
correlate with what the patient perceives as effective improvement.[1] In all patients breathing function had improved in those that had reported limitation
beforehand, while it was perceived as unchanged or even improved in those who had
good breathing before. This latter fact is interesting and may be due to the realization
by the patient that the perceived “good breathing” preoperatively was actually not
so when compared with the postoperative breathing. The difficulty is discriminating
what variable made the greater difference, considering that many factors matter in
relieving obstruction and that the effect of maneuvers on the septum, valves, and
turbinates cannot be analyzed in isolation. In fact, some form of septoplasty was
performed in over 80% of patients and valves and sidewall were often addressed, especially
in secondaries, etc. No discrimination was thus attempted in understanding which factors
contributed, and in which percentage, to improved breathing. Repeat CT scan, which
would have been an ideal tool, was considered not justifiable in this patient population.
Clinical examination was undertaken by a long and thin speculum. Although no direct measurement of the
distance between septum and medial turbinate edge was done, it was commonly observed
that the position of the turbinate remained generally lateralized. Save for some instances
in which mucosal hypertrophy was still evident (or possibly had already recurred),
it was our constant impression that lateralization was maintained. Obviously, these
findings had to be tempered by and related with the changes due to septoplasty.
Noted complications: No postoperative bleeding occurred in any of the patients. Postoperative bleeding
was defined as any occurrence of bleeding requiring operative intervention with cauterization
or ligation. Thus, some occasions of minor oozing occurring on the following morning
postoperatively when the Vaseline gauze between Doyle and turbinate was removed were
not considered as “postoperative bleeding.” They were treated by simply replacing
the Vaseline gauze for another day. In no instance purulence, foul drainage, prolonged
crusting, rhinorrhea, and synechiae were noted at follow-up. No residual crusting
was found at the three months postoperatively, although some patients had more crusting
than others over the first two or three weeks.
Discussion
A wide variety of treatment options exist for the management of ITH, indicating a
remarkable lack of consensus prevalently due to the corresponding lack of perspective
and comparative studies with adequate follow-up, as well as to the multiple variables
at play in the assessment of airway function.[1]
[2]
[3]
[4]
[5]
[6] Obviously, turbinoplasty is very often performed during rhinoplasty, according to
the commonly accepted logic of performing septoplasty together with reduction of the
enlarged contralateral ITH.[2]
[7]
[8]
[9]
[26] Interestingly, at least among plastic surgeons, conventional methods of turbinate
reduction are generally preferred on the use of newer techniques.[4]
The goal of surgical treatment should be reducing the volume of the inferior turbinate
while preserving function, and it stands to reason that an effective treatment should
address both bony and mucosal components of ITH.[1]
[2]
[3] Various studies implicate that bone matters more, especially in compensatory hypertrophy,
together with the fact that some mucosal shrinkage should also spontaneously occur
in compensatory ITH once the related septal deviation is corrected.[2]
[10]
[11]
[12]
General agreement exists on the fact that the surface mucosa itself should be spared
as much as possible, and this emphasized the role of submucosal turbinoplasty, which
is, however, a term that applies both to submucosal soft tissue reduction targeting
the erectile tissue under the epithelium as well as submucosal bone removal. Submucosal
turbinoplasty as described by Rohrich in 2001 and employed by the senior author for
many years, consists in the sequence of incision, elevation-exposure of the conchal
bone, extraction of bony fragments, out fracture, and cautery of the raw mucosal margins.[7] Piecemeal bony excision, as commonly done by the use of a Takahashi forceps, is,
however, prone to bleeding, mucosal tears, and subsequent prolonged crusting. This
is due to the vascular anatomy of the inferior turbinate where the vessels travel
in intimate relationship with the bone, as described earlier, and in fact occurred
in the senior author's practice in multiple occasions in the past.
It thus seems logical that lateralization of the inferior turbinate has been recently
favored by many authors as a simple technique that preserves function completely without
any risk of bleeding.[17] Lateralization is generally done by outfracture. Although the outcome of various
studies was that the technique is effective with a durable reduction of angle and
distance between the turbinate bone and the lateral wall, some authors noted the tendency
of lateralized turbinate to recur in the long term. This essentially led to the procedure
being used mainly as a complementary technique together with others, rather than a
standalone method.[3]
[6]
[13]
[17]
Interestingly, following their previous work on submucosal turbinoplasty,[7] Rohrich et al later described closed microfracture of the turbinate bone inside
an intact mucosal sac as the preferred method for treating ITH.[16] Microfracturing and the related comminution was the key element they identified
in reducing the risk of recurrence of the lateralized turbinates in the original position.
With these premises, it would make sense, while adopting the principle of avoiding
extraction of bone and the related risk of bleeding, to adopt a technique which would
reliably and permanently modify the bone architecture by precise resection while completely
sparing soft tissue and mucosa. This would seem preferable to employing an elevator
or a nasal speculum and causing possibly uncontrolled greenstick fractures by pressure
only. Piezo can be helpful to this regards: through an incision measuring only a few
millimeters, the insert can create a specific cut in the bony exactly at the line
of maximum angulation, which is verified and planned preoperatively, depending on
the CT or, preferably, CBCT imaging, with further help as well as of a possible 3D
bone reconstruction. This complete linear cut is done with a long insert where the
uncinate bone angles off the nasal sidewall ([Fig. 4a–c]). If one is not sure that the direction of the insert and position of cut is at
this spot, the angle of approach can be changed, and a new path of cut adopted. Not
being a greenstick fracture but a true cut, its effect is stable and irreversible
and the turbinate position has no risk of recurring. Bone is not removed, but its
configuration is changed permanently.
Fig. 4 Comparing techniques (conventional outfracture versus piezo lateralization) for the
treatment of inferior turbinate hypertrophy in rhinoplasty patients.
Keeping Doyle splints for one week, as customary in rhinoseptoplasty, may help in
further preventing any remedialization.[2]
[16] Piezo technology, by definition, will spare soft tissue and vessels and has gained
considerable momentum and widespread acceptance in rhinoplasty over the last few years
especially for osteotomy and osteoplasty maneuvers.[29] In the senior author's experience, piezo is used in multiple steps of rhinoplasty
in every case, primary or secondary. It thus becomes logical to use the same insert
that is employed for a lateral osteotomy or for posterior septal harvesting to also
fracture the uncinate bone precisely, without causing any bleeding. It is to be noted
that this is a different technique from the “sonic rhinoplasty” based on the use of
an ultrasonic bone aspirator which emulsifiers and extracts bone.[30]
Additionally, on the premise stated earlier that bony and mucosal hypertrophy is concurrent
in ITH, it also sounds reasonable to employ an adjunct treatment modality that, after
bony hypertrophy is corrected, will then somewhat reduce the mucosa component, where
it is thicker, that is, medially. This is why we add intramucosal microneedling with
a unipolar electrode Bovie tip. The rationale is that intraturbinal thermocoagulation
should cause less damage to mucosa than surface cautery, essentially inducing submucosal
fibrosis. The “shrinkage” effect on the mucosa may of course well be temporary, but
it will cause virtually no harm.[Table 1] summarizes the main considerations on the treatment of turbinates using piezoelectric
technology.
Table 1
Advantages and disadvantages
|
Advantages
|
Disadvantages
|
|
Lateralization of the turbinates is not based on a greenstick fracture but on a piezo-assisted
cut through the uncinate bone at its angle. This prevents recurrence.
|
The cost of the piezo equipment.
|
|
The piezo insert is the same used in other parts of the rhinoseptoplasty.
|
The technique may not be justifiable for standalone turbinoplasty.
|
|
The incision for access of the insert is limited.
|
|
|
Piezo-assisted osteotomy of the uncinate bone spares vessels close to the bone and
prevents bleeding.
|
|
|
Additional intramucosal unipolar cautery on fine needle may help reduce mucosal component
of inferior turbinate hypertrophy.
|
|
|
The technique is simple and fast.
|
|
|
No complications were noticed in the series studied.
|
|
The results described in this article need to be implemented by a longer term follow-up,
and possibly by an objective method of assessing the stability of lateralization.
Obviously, a repeat CBCT scan would be ideal, but this is hard to justify in the setting
of a clinical practice.
Conclusion
The ideal surgical management of ITH should be efficient in relieving obstruction
symptoms and kind to turbinate function. Piezo outfracturing of the turbinate bone
combined with unipolar microcauterization is a safe, fast, easy, and effective technique
for treating mild, moderate, and severe ITH without the risk of bleeding and prolonged
crusting. Surgeons already employing piezoelectric technique for different steps of
rhinoseptoplasty should have a low threshold for performing this technique to correct
ITH.
