|Year : 2016 | Volume
| Issue : 3 | Page : 504-509
Microdebrider-assisted turbinoplasty against submucosal cauterization in inferior turbinate hypertrophy
Ahmed Ragab1, Omar Elbanhawy1, Ahmed Khashba2, Ayman Ali1, Mahmoud AbdelAziz3
1 Department of Otorhinolarygology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Al-Galaa Hospital, Egyptian Military Medical Academy, Cairo, Egypt
3 Hearing and Speech Institute, Embaba, Giza, Egypt
|Date of Submission||14-Jun-2015|
|Date of Acceptance||02-Aug-2015|
|Date of Web Publication||23-Jan-2017|
73 Saied Street, Tanta
Source of Support: None, Conflict of Interest: None
This study was carried out to compare postoperative outcomes between microdebrider-assisted turbinoplasty and submucosal cauterization (diathermy) in the treatment of chronic inferior turbinate hypertrophy using subjective and objective criteria.
Chronic nasal obstruction is one of the most common symptoms in otorhinolaryngology, and hypertrophy of the inferior turbinates is the most frequent etiology.
Patients and methods
This prospective study was carried out over 25 patients with nasal obstruction and hypertrophied turbinate mucosa refractory to medical treatment. All patients enrolled in the present prospective randomized study were subjected to microdebrider-assisted turbinoplasty on the right side (group A operation) and a submucosal cauterization on the left side (group B operation). Postoperative changes in the degree of nasal obstruction, nasal discharge, and crustations were evaluated at 1 week, 1 month, and 6 months by nasal endoscopy. The patient satisfaction score was evaluated at 6 months postoperatively. Rhinomanometric measurement was also performed preoperatively and at 6 months postoperatively for objective comparison.
Microdebrider-assisted turbinoplasty was statistically better in comparison with submucosal cauterization regarding postoperative nasal obstruction at 1 month (P = 0.025) and 6 months (P = 0.049), nasal crustations at 1 month (P = 0.004) and 6 months (P = 0.017), postoperative patient satisfaction at 6 months (P = 0.042), and rhinomanometric measurement at 6 months (P = 0.001). There was improvement of nasal discharge and headache with no statistically significant difference between both groups (P ≥ 0.05).
Microdebrider-assisted turbinoplasty is more effective and satisfactory than submucosal cauterization in relieving nasal obstruction subjectively and objectively.
Keywords: microdebrider, nasal obstruction, submucosal cauterization, turbinate hypertrophy, turbinoplasty
|How to cite this article:|
Ragab A, Elbanhawy O, Khashba A, Ali A, AbdelAziz M. Microdebrider-assisted turbinoplasty against submucosal cauterization in inferior turbinate hypertrophy. Menoufia Med J 2016;29:504-9
|How to cite this URL:|
Ragab A, Elbanhawy O, Khashba A, Ali A, AbdelAziz M. Microdebrider-assisted turbinoplasty against submucosal cauterization in inferior turbinate hypertrophy. Menoufia Med J [serial online] 2016 [cited 2020 Mar 29];29:504-9. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/504/198688
| Introduction|| |
The inferior turbinate is an important structure, playing a vital role in the nasal physiology. It has many functions, including filtration, warming, and humidification of the inspired air, in addition to the regulation of nasal airflow  . Chronic nasal obstruction is one of the most common human problems and a very frequent symptom in the ear, nose, and throat field. Hypertrophy of the inferior turbinates is the most frequent cause and may be related to allergic rhinitis, nonallergic rhinitis with eosinophilic syndrome, or iatrogenic rhinopathy  . Medical treatment options such as antihistamines, topical decongestants, and corticosteroids are commonly prescribed to reduce the size of the turbinate with the aim of restoring nasal function. However, some cases show only slight improvement, whereas others are even refractory to these medical treatments and the patients complain about persistent symptoms. In these cases, surgical reduction of the inferior turbinate can be attempted  . Many techniques of turbinate reduction have been performed, including partial or total turbinate resection, cauterization, cryotherapy, laser therapy, and radiofrequency ablation. The variety of surgical techniques available indicates the lack of consensus on the optimal technique  . With the introduction of microdebriders to rhinosurgery by Setliff et al.  , many surgeons began to perform submucosal resection during inferior turbinoplasty, utilizing the advantages of the powered system  . In contrast, submucosal cauterization remains a very popular technique because of its technical ease and lack of complications  . Wound healing is a highly organized process, involving inflammation, cell proliferation, matrix deposition, and remodeling, and it is regulated by a wide variety of growth factors  . The aim of this study is to compare the results of endoscopic microdebrider-assisted turbinoplasty with submucosal cauterization of the inferior turbinates in the treatment of chronic inferior turbinate hypertrophy.
| Patients and methods|| |
A prospective comparative study was carried out over 25 patients who presented with nasal obstruction and hypertrophied turbinate mucosa refractory to medical treatment, from October 2013 to October 2014. All of these patients had symptoms and signs of nasal obstruction and stuffiness related to congested turbinate mucosa that did not respond well to medical treatment. After routine physical ear-nose-throat examination, focusing on a detailed nasal examination, every patient underwent endoscopic nasal evaluation. Patients with prominent mucosal hypertrophy were selected by means of a decongestion test because patients with bony hypertrophy covered with a thin layer of mucosa are not good candidates for microdebrider-assisted turbinoplasty and submucosal cauterization. Patients who had undergone any kind of surgery for the treatment of turbinate hypertrophy, septal deviation, or nasal polyps as well as those who were thought to have causes of nasal obstruction other than inferior turbinate hypertrophy were excluded from the study. Informed consent was obtained from all patients and the study was approved by the ethical committee of the hospital. Twenty-five patients were treated with the microdebrider on the right side (group A) and submucosal cauterization (diathermy) on the left side (group B).
Subjective symptoms such as nasal obstruction, nasal discharge, crustation, and headache were evaluated at 1 week, 1 month, and 6 months after the procedure and patients' satisfaction with the procedure was evaluated preoperatively and at 6 months after the procedure according to a four-point scale ([Table 1])  . Rhinomanometric evaluation was also performed as an objective comparison method preoperatively and 6 months after the procedure. A (Rhinomanometer-NR7D; Mercury electronics Scotland Ltd., Glasgow, UK) device was used for rhinomanometric evaluation. Active anterior rhinomanometry was applied in all patients in accordance with the rhinomanometry standardization committee's suggestions in 1984  .
|Table 1 The four - point scale of nasal symptoms and patient satisfaction |
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In every patient, the hypertrophic inferior turbinate was reduced using the microdebrider on the right side (group A operation). A submucosal diathermy was performed on the left side (group B operation). The procedure was performed under general anesthesia. In right side A (Storz Undrive II model 20711020, KARL STORZ GmbH & Co. KG - Tuttlingen,Germany) was used for microdebrider-assisted turbinoplasty. Topical lidocaine 4% and a vasoconstrictor (eg, phenylephrine HCl) are applied via spray to each nasal cavity, followed by injection of 1 mL 1% lidocaine with 1:100,000 epinephrine into each inferior turbinate. The body and tail of the inferior turbinate were infiltrated with normal saline to facilitate flap elevation. Using a number 15 blade, a vertical incision at the most anterior end of the inferior turbinate was performed and it was taken down to the bone. A nonsharp elevator was utilized to create a flap tunnel along the medial and inferior surface of the turbinate till its posterior end ([Figure 1]). The microdebrider blade (2 mm) facing the bony wall was passed through the created plane to remove redundant erective tissue ([Figure 2]). After this, any redundant mucosa from the inferior and lateral wall of the inferior turbinate was removed. The inferior turbinate was replaced in its lateral position ([Figure 3]).
|Figure 1: The nonsharp elevator utilized to create a flap tunnel along the medial and inferior surface of the turbinate till its posterior end. IT, inferior turbinate; MT, middle turbinate; NS, nasal septum.|
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|Figure 2: The microdebrider blade (2 mm) facing the bony wall passed through the created plane to remove redundant erective tissue. IT, inferior turbinate; NS, nasal septum; SP, submucosal pocket.|
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|Figure 3: The inferior turbinate replaced in its lateral position. IT, inferior turbinate; NS, nasal septum.|
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The left side was prepared with gauze containing adrenaline 1:200 000. A special pointed needle insulated except for 5 mm at its tip was connected to a standard surgical coagulation diathermy source earthed to the thigh, under endoscopic guidance with visualization of the whole turbinate; the needle was entered through the turbinate anterior end and advanced close to the turbinate bone and parallel to the floor of the nose; the diathermy circuit was closed while the needle was gradually withdrawn so that submucosal linear burn resulted with minimal injury to the mucosa. Usually, 2-3 runs were needed for the left side. A Merocel nasal (Medtronic, Minneapolis, U.S.A.) pack was divided longitudinally into two halves and placed within both nasal passages. Patients were then followed for 24 h for any potential complications. Those who did not have any problems were dismissed and scheduled for follow-up visits.
Statistical presentation and analysis of the present study was conducted using the mean and SD, the Student t-test (unpaired), and the χ2 -test by SPSS V17 (IBM Corporation, New York, United States). The unpaired Student t-test was used to compare between two groups of quantitative data. χ2 : the hypothesis that the row and column variables are independent, without indicating strength or direction of the relationship.
| Results|| |
Regarding preoperative data, there was no statistically significant difference between both groups (P ≥ 0.05). The mean time of the operation in group A was 11.76 ± 1.832 min. In group B, the mean time was 17.88 ± 4.136 min. It was a highly significant difference between the two groups (P < 0.001). All cases in group A showed mild bleeding mainly at the site of insertion of the microdebrider blade except six cases (20%) in which the bleeding was noticeable and was controlled using bipolar diathermy. In group B, only two cases had mild bleeding (6.66%) and the bleeding was controlled and the procedure was not affected.
At 1 week postoperatively, groups A and B were compared regarding the postoperative data (nasal obstruction, discharge crustations, and headache). There was significant improvement in nasal obstruction in group A compared with group B (P = 0.010) and there was an improvement with no significant difference with regard to discharge, crustation, and headache in both groups (P ≥ 0.05) ([Table 2]).
|Table 2 Comparison between the right side (treated by microdebrider) and the left side (SMC) with regard to postoperative data at 1 week |
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At 1 month postoperatively, there was significant improvement in nasal obstruction (P = 0.025) and crustations (P = 0.004) in group A compared with group B and improvement in nasal discharge and headache in both groups, with no statistically significant difference between both groups (P ≥ 0.05) ([Table 3]).
|Table 3 Comparison between the right side (treated by microdebrider) and the left side (treated by SMC) with regard to postoperative data at 1 month |
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At 6 months postoperatively, there was significant improvement in nasal obstruction (P = 0.049) and crustations (P = 0.017) in group A compared with group B and improvement in discharge and headache in both groups with no statistically significant difference (P ≥ 0.05) ([Table 4]).
|Table 4 Comparison between the right side (treated by microdebrider) and the left side (treated by SMC) with regard to postoperative data at 6 months |
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Patient satisfaction was more significant in group A compared with group B after 6 months (P = 0.042) ([Figure 4]).
|Figure 4: The satisfaction score was higher in the right side compared with the left side after 6 months, with a statistically significant difference.|
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Rhinomanometric measurements showed a significant decrease in nasal resistance in group A compared with group B after 6 months (P = 0.001) ([Figure 5]).
|Figure 5: Results of rhinomanometry preoperatively and 6 months postoperatively.|
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| Discussion|| |
In the current study, there was no statistically significant difference between both groups with regard to preoperative data. Regarding the operative time, the microdebrider procedure had a shorter duration (11.76 min) with significant difference compared with submucosal cauterization (17.88 min). This concurs with Hesham et al.  . In the early postoperative period, there was a significant difference in the mean time between the operation and apparent healing as it was shorter in the side treated by microdebrider-assisted turbinoplasty; this concurs with study conducted by Lee and Chen  . In the current study, postoperative data were compared at 1 week: nasal obstruction, discharge, crustations, and headache revealed significant improvement in obstruction in the microdebrider group. There was no significant difference with regard to discharge, crustation, and headache between both groups. At 1 and 6 months postoperatively, significant improvement was observed in nasal obstruction and crustation in the microdebrider group compared with the submucosal cautery (SMC) group and improvement in nasal discharge and headache was observed in both groups with no statistically significant difference. Patient satisfaction from the procedure revealed that the satisfaction score was higher in the microdebrider group compared with the SMC group after 6 months, with a statistically significant difference. Similar results were reported by Kizilkaya et al.  . The total nasal resistance measured by rhinomanometry preoperatively and postoperatively revealed a statistically significant difference in nasal resistance in the microdebrider group compared with the SMC group at 6 months postoperatively; this is similar to the results reported by Lee and Lee  . The current results of the microdebrider procedure coincide with those of Cingi et al.  as they concluded that microdebrider-assisted partial turbinoplasty is more effective and satisfactory in relieving nasal obstruction. Similar results were also reported by Kassab et al.  , who concluded that success rates were 90% for the microdebrider group and 85% for the diode laser group, and the two techniques are equally safe, reliable, successful, and noninvasive. However, Hesham et al.  concluded that extraturbinal microdebrider-assisted inferior turbinoplasty could be a good option for all cases of inferior turbinate hypertrophy reserving the intraturbinal technique for patients with possible delay of mucosal regeneration, for example, diabetic patients, older patients, and patients not accepting the relative delay in the improvement of their symptoms. The current results of SMC are relatively similar to the results of Kafle and colleagues, who concluded that submucosal diathermy (SMD) should be performed in all patients with inferior turbinate hypertrophy who were unresponsive to medical treatment. If inferior turbinate hypertrophy recurs after SMD, partial resection of the inferior turbinate should be carried out  . In contrast, Salzano et al.  concluded that partial inferior nasal turbinectomy was the best method of treatment as it was the most effective procedure that maintained satisfactory nasal physiologic integrity without damaging the nasal mucosa or underlying nerves. Chand et al.  concluded that submucosal diathermy was found to be more successful in relieving patients' symptoms and decreasing the size of the inferior turbinates when compared with mucosal electrocautery. Similar results were reported by Imad et al.  , who concluded that submucosal diathermy is a safe and better procedure with respect of bleeding, pain, crusting, and healing compared with partial inferior turbinectomy. Manikandan et al.  concluded that inferior turbinate hypertrophy is effectively reduced by submucosal diathermy. It is an inexpensive, safe, and effective procedure for long-term positive outcomes. In the current study, our results can probably be explained by the fact that SMC may cause edema in the tissue, which starts a few days after the procedure. Prolonged or latent edema may also be a factor responsible for the long-term decrease in patient satisfaction with SMC. Another factor that should be borne in mind is that SMC decreases the size of the inferior turbinate, facilitating fibrosis, which may have a certain latency period. However, microdebrider directly removes the enlarged submucosal and bony tissue of the turbinate, causing instant relief of symptoms. From this point of view, microdebrider turbinoplasty was better compared with SMC. One weakness of this study is the small patient numbers, which has limited the statistical power of our results. Despite this, where statistical significance has not been obtained, a consistent trend in favor of the microdebrider was observed in almost all the postoperative criteria assessed.
| Conclusion|| |
Both microdebrider-assisted turbinoplasty and submucosal cauterization are efficient methods for relieving nasal obstruction related to inferior turbinate hypertrophy. However, microdebrider-assisted turbinoplasty is more effective and satisfactory than submucosal cauterization in relieving nasal obstruction subjectively and objectively, with lesser incidence of postoperative edema, crustations, and discharge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]