Keywords
cautery - nasal obstruction - trichloroacetic acid
Palavras-chave
cauterização - obstrução nasal - ácido tricloroacético
Introduction
Hypertrophy of the inferior turbines is a common cause of chronic nasal obstruction. It can be started by inflammatory processes, including allergic and nonallergic rhinitis. It causes significant morbidity, once it determines a negative impact over the inferior airways, impairments in craniofacial development in children and altering in speech and language.
Corticosteroids and systemic and topical decongestants, as well as symptomatic, are used in the treatment of this condition; however, surgery becomes necessary when no satisfactory result is achieved with clinical treatment.
Several surgical techniques of the inferior turbines were already described: electrocauterization, cryotherapy, laser, radiofrequency, partial or total turbinectomy, turbinoplasty, but there are still controversies as to which offers better results and fewer complications. The trichloroacetic acid, as known as trichloroethanoic acid, is an analogue of acetic acid, considered safe by CPDB (carcinogenic potency database). Its use is wide, being used on the skin or mucosa by various medical specialties.
The main objective of this study is to evaluate the efficacy of the chemical cauterization of inferior turbines with trichloroacetic acid for rhinorrhea and nasal obstruction. We also studied the complications, tolerance, viability and time of the procedure.
Method
In this clinical Trial were selected 29 patients with condition of nasal obstruction and/or persistent serous rhinorrhea, who showed indication of surgical treatment to correct the hypertrophy of the inferior turbines. The individuals were treated as outpatients, from January 2007 to December 2009. The project was approved by the Ethics and Research Committee of the institution, protocol number 043/2007.
The research included individuals of both sexes, between 12 to 60 years of age, with hypertrophy of the inferior turbines and nonresponsive to clinical treatment with topical nasal corticosteroids. Were excluded: patients incapable to provide consistent answers, pregnant women, individuals submitted to previous nasal surgery or that presented allergy to the components used in the treatment. After the analysis of the inclusion and exclusion factors and the agreement to the free and informed consent, was scheduled a date for the intervention. Prior to the procedure, patients were asked to quantify, through a visual analogue scale, the severity of the nasal obstruction and/or rhinorrhea. The score went from 0 to 10, being 0 the absence of symptom and 10 its highest expression. After the procedure, the individual was asked to use the same scale to quantify the pain caused by the method. The interventions consisted of, firstly, the retraction of the turbines with naphazoline 0,5% and local anesthesia with neotutocaine 2% followed by xylocaine 10% for 10 minutes. Then, it was made the infiltration of 0,03 mL of trichloroacetic acid 30% through insulin syringe and spinal needle number 22, in three points of the inferior turbine: tail, mid section, and head.
The initial grade of the symptoms was compared to the evaluation performed after 12 months of the realization of the procedure. The pain caused by the infiltration was also assessed. The statistical tests used were ANOVA followed by the t student test.
Results
Of the 29 patients submitted to the procedure, 17 completed the evaluation one year after the procedure.
Regarding the nasal obstruction, was observed a statistically relevant improvement at the symptom evaluation by the visual analogue scale, which before the procedure showed an average of 7,9 (± 0,5) points by VAS and at the evaluation after one year evidenced an average of 2,5 (± 0,7) points.
The evaluation results of the rhinorrhea symptom showed a decline of the value of average VAS score of 4,6 (± 0,9) points before the cauterization to 1,8 (± 0,8) points in the evaluations performed one year later.
Regarding the pain caused by the procedure, we found an average of 6,8 (± 0,7) VAS points. The symptom did not remain for more than 24 hours after the procedure. Synechiae were observed in 2 patients, which were of small magnitude, and were corrected in the ambulatory during subsequent consultations. Epistaxis occurred in four cases, all of mild degree and resolved spontaneously.
Discussion
Nasal obstruction was a complaint common to all 17 patients that completed our evaluation, and all of them reported some degree of improvement. Using the visual analogue scale, we noticed that the average of obstruction found before the procedure was of 7,9 (± 0,5) and fell to 2,5 (± 0,7). Similar results were found by other authors[1]
[2]
[3], however, in these studies, the application of the trichloroacetic acid was topical on the inferior turbine and in higher concentration, of 80%.
Almost all patients reported reduction of rhinorrhea, with initial visual analogue scale index of 4,6 (± 0,9), falling to 1,8 (± 0,5) after one year of the procedure. Yao et al.
[4] also observed improvement of other symptoms of allergic rhinitis, such as rhinorrhea and sneezing, after the application of the trichloroacetic acid, and demonstrated in recent research, that occurred a reduction of the mucosa infiltration of T cells, Th2 type, admittedly responsible by the allergic answer of rhinitis, after the topical utilization of trichloroacetic acid, suggesting that the migration of these cells was inhibited by the local action of the acid.
The comparison of the infiltration of turbines with steroids and botulinum toxin presented by Yang et al.
[5] showed that the toxin is safest and most efficient than steroids in the treatment of allergic rhinitis with hypertrophy of the turbines, reducing nasal obstruction, rhinorrhea, sneezing and prurience, but the effect has limited duration (20 weeks), and we should point out that its cost is elevated. In our study after one year of the procedure, the improvement was significant and the cost of the solution of trichloroacetic acid is reduced.
The infiltration of the inferior turbines with trichloroacetic acid proved safe and with few complications. Only two patients presented synechiae, resolved in ambulatory regimen. There was no significant history of bleeding, frequent occurrences in the turbinectomy and turbinoplasty procedures. The pain had spontaneous resolution in less than 24 hours. There were no bigger complications, such as those associated to infiltration of steroids which, despite being an old practice in otorhinolaringology, may lead to visual loss, transitory or permanent, as described by Martin et al.
[6] and Marby et al.
[7]. The incidence of this fact is low, estimated as 0,006%, but the effect can be devastating. The mechanism is probably due to the embolization of the retinal arterioles, which suffer this injury due to retrograde flow of anastomoses between the anterior and posterior ethmoidal arteries and the ophthalmic artery. This grave complication did not occur in our small casuistry, but, due to the physicochemical characteristics of acids, that do not disseminate at distance, it is not likely to happen.
Regarding the pain reported by patients, the average found was of 6,8 (± 0,7) points.
None of the patients denied undergoing the procedure on the contralateral nostril and the symptom did not remain for over a few minutes after the procedure. We shall reconsider the previous time of anesthesia, as well as try other topical anesthetic agents for greater comfort during and after the procedure.
Conclusion
The infiltration of trichloroacetic acid in the inferior turbines proved to be safe and efficient regarding the decrease of the symptoms of nasal obstruction and serous rhinorrhea in studied patients, even after one year after the procedure. We believe this technique can be an alternative to the surgical interventions that need general anesthesia. Further studies will be of great value, especially to assess the efficacy of the method for control of the rhinorrhea related to “Rhinitis of elderly”, knowing that these patients may present symptoms of difficult control and frequently present contraindications to surgical procedures.
