By Giampiero Neri, Fiorella Cazzato, Elisa Vestrini, Pasquina La Torre, Giampaolo Quaternato, Letizia Neri and also Lucia Centurione
Submitted: October 3rd 2018Reviewed: January 17th 2019Published: march 25th 2019
Chronic nasal obstruction as result of hypertrophic rhinitis is commonly connected with perennial allergic and also nonallergic rhinitis. It is not a an easy enlargement that mucosal and submucosal tissues, however it is identified by deep histological modifications. This pathology, a really frequent problem encountered in rhinological practice, has a significant impact on high quality of life. Patients typically complain around sneezing, rhinorrhea, frontal headache, postnasal drip, snoring, clogged nasal ducts, and sleep disorders. When medical therapy fails, operation reduction of worse turbinates is mandatory. A large variety of surgical methods in literary works exist, yet there is a lack of consensus about which is the proper method to perform. In this chapter, we describe the most vital techniques of inferior turbinate reduction with advantages and flaw of each one.
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Keywordsturbinate hypertrophynasal obstructionnasal surgerytechniquesturbinoplasty
chapter and author info
AuthorsGiampiero Neri*Neurosciences, Imaging and Clinical sciences Department, university “G. D’Annunzio”, ItalyFiorella CazzatoNeurosciences, Imaging and also Clinical scientific researches Department, college “G. D’Annunzio”, ItalyElisa VestriniNeurosciences, Imaging and Clinical scientific researches Department, university “G. D’Annunzio”, ItalyPasquina La TorreNeurosciences, Imaging and Clinical scientific researches Department, university “G. D’Annunzio”, ItalyGiampaolo QuaternatoNeurosciences, Imaging and also Clinical sciences Department, university “G. D’Annunzio”, ItalyLetizia NeriNeurosciences, Imaging and also Clinical scientific researches Department, university “G. D’Annunzio”, ItalyLucia CenturioneMedicine and Aging sciences Department, ar of human Morphology, college “G. D’Annunzio”, Italy
*Address every correspondence to: neri
From the Edited Volume
RhinosinusitisEdited through Balwant singh Gendeh
Edited by Balwant singh Gendeh and Mirjana Turkalj
Chronic nasal obstruction is a really frequent problem in rhinological practice that severely interferes with the high quality of life <1>. The most common cause of this complain is chronic hypertrophic rhinitis. It consists of a chronical ede of the inferior turbinate <2>.
Turbinate hypertrophy, commonly associated with perennial allergic and also nonallergic rhinitis <1>, is no a basic enlargement the mucosal and also submucosal tissues, but it is identified by deep histological changes such as severe damage of the epithelial barrier, disappearance of ciliated and also goblet cells, inflammation infiltration of the lamina propria, fibrosis, influential venous congestion, and also basement membrane discontinuity <2>.
Patients usually complain about sneezing, rhinorrhea, postnasal drip, frontal headache, blocked nasal passages, sleep disturbance, and snoring <3>.
When clinical treatment with topical corticosteroids, antihistamines, and also decongestants fails, surgical reduction of worse turbinates might be attempted.
The goal of turbinate surgical treatment is to enhance nasal patency by minimizing complications such us postoperative hemorrhage, crusting, foul odor, and the “empty sleep syndrome” <4>.
There is a selection of turbinate procedures, but there is a lack of consensus about which method is the ideal <5>.
Turbinate hypertrophy can be separated into primary and secondary. The major hypertrophy is regarded the submucosal component, while the an additional hypertrophy is because of contralateral septal deviation and is pertained to the bony component of the turbinate. The is important to distinguish these two varieties of hypertrophy in stimulate to decision the appropriate procedure come perform. The anatomic radiologic examine (Figure 1) and the rhinomanometric review (Figure 2) are mandatory for surgical indication <6>.
The radiologic study with head-CT shows a normal anatomy the the turbinates and also the nasosinusal system.
Rhinomanometric evaluation prior to (A) and after (B) application of nasal topical decongestant reflects the innovation of respiratory nasal flux.
2. Surgical techniques
Turbinate reduction techniques can be separated into four categories <7>:Extramucosal debulking procedures
Superficial extramucosal procedures
2.1 Extramucosal debulking procedures
These measures include:Total turbinectomy
Microdebrider-assisted turbinoplasty (extramucosal technique)
2.1.1 full turbinectomy
It is a an approach that was defined for the first time in the last 10 year of the nineteenth century. Jones in 1895 and Holmes in 1900 presented the concept of complete turbinectomy <8>.
This technique is taken into consideration the most radical surgical method on the inferior turbinate. After having fractured, the bone plate of the inferior turbinate (Figure 3), levering native the worse meatus, with an angled scissors, the inferior turbinate is dissected for its entire length continuing to be adherent to the lateral wall of the sleep cavity.
For the immediate advantage that the patience obtains, it is often taken into consideration as safe and effective though its significant complication is the feasible bleeding, avoidable, however, both using enough nasal swabs and avoiding to treat patients that take anticoagulants <9>.
Unfortunately, this kind of surgery, exceptionally aggressive, can later lead to dry nose syndrome or even the syndrome that the empty nose v a paradoxical obstruction. The obstructive occasion is as result of the ns of common nasal resistance and also the development of a laminar wait column. This situation causes a bad contact in between the air and also the sleep walls, the mucosa, because of the lack of the sensory fibers of the inferior turbinate, mirrors a palliation or even a loss of the respiratory flow <6>.
The transformed aerodynamics pattern, early out to full turbinectomy, generates many complications such together copious postoperative bleeding, quantitative reduction of the ciliary movement, mucosal dryness, and deficit of rubber clearance. Every this create stagnation the secretions, crusts formations (sometimes foul-smelling), and frequent infections v gradual advancement of dry inflammatory develops affecting the pharynx and also larynx. Precisely since of the complications, this method has now fallen into disuse <9>.
TASCA states that the is dorn to transform the sleep cavities into rigid and also inanimate tubes, can not to execute the attributes of congestion and also decongestion, depriving lock of their natural function <10>; and for Huizing and de Groot, complete turbinectomy is a nasal crime, and they carry out not think about it valuable to do the resection of an ext than a 3rd or fifty percent of the inferior turbinate unless it is a tumor <11>.
2.1.2 Partial turbinectomy
The partial turbinectomy (Figure 4) is provided to border the huge surgical resections that are performed with total turbinectomy, and also consists in the remove of the mucosa and also bones that the anterior third of the inferior turbinate. The level of resection is directly proportional to the degree of hypertrophy. Initially, the mucosal and also the submucosal tissue space removed, and also if there is bone hypertrophy, a tiny bone resection is likewise performed. Over there are number of partial turbinectomy techniques.
The oldest an approach is the crushing and also trimming introduced by Kressner in 1930. Other technique is selective mucosotomy, which consists of the removed of the anterior or/and the posterior region of the turbinate following characterized section lines. The diagonal resection is composed in a sagittal exeresis with the purpose of maintaining the head of the turbinate and eluting the posterior an ar of the turbinate. The horizontal resection the the worse edge of the turbinate avoids the hazard of bleeding indigenous the sphenopalatine artery <12>, which rather occurs in the diagonal resection <7>.
The degloving an approach was suggest by Chevretton etal. It consists of the resection the a huge part the the turbinate, leaving the bone and also the periosteum intact <7, 13>.
TASCA etal. Reported the the only ideal techniques are “Crushing v remodeling” and “Resection of the tail.” the is preferable to execute a resection that the posterior region of the inferior turbinate, since the remove of the head of turbinate causes a an excellent functional damage. It creates a deficit that the mucociliary clearance and the worse turbinate loser its duty of directing the inspiring currents <10>.
Crushing through remodeling is indicated if the hypertrophy is both anterior and also posterior and permits to respect the sensible capacity of the remaining section of the turbinate. The turbinate is compressed using details pliers and also then lessened by cutting parallel or slightly diagonal strips starting from the reduced edge. After ~ the medial fracture of the turbinate performed v a smooth and also chamfered instrument (the take care of of a Cottle chisel can be used), it is squeezed with modified-Kressner tongs both anteriorly and posteriorly. The dimension of the turbinate is reduced by remove a piece from its fairly flaccid bottom edge through Heymann-type scissors. If necessary, a component of bone is removed. Finally, the turbinate remaining laterally is repositioned. The is advised to carry out a second surgical time if the hypertrophic tissue is excessive, preventing to eliminate it in a solitary time <14>.
Resection that degenerated tissue: if a component of the turbinate is damaged irreversibly, that is eliminated using lengthy angled scissors or a loop <14>.
Even if partial inferior turbinectomy is a straightforward and efficient surgical procedure, that is same troublesome if no performed correctly. Excessive resection of the inferior turbinate have the right to lead to peri- or postoperative bleeding, from medial and also inferior surface of the inferior turbinate, synechiae through the sleep septum and also floor of sleep cavity, frequent post nasal blood drip, nasal crusting, and also atrophic rhinitis. By using appropriate tools and also limiting demolition, this complications deserve to be avoided <15>.
A study by Passali etal. Demonstrated exactly how the partial turbinectomy technique performed in ~ the level of the inferior turbinate resolves many of the nasal obstruction. This method however, even if minimally, causes damage come the nasal mucosa and also therefore the is crucial that the surgeon is competent to protect against complications <1, 16>.
Sapci etal. Reported that the use of radiofrequency to alleviate hypertrophy of turbinates leader to an innovation of nasal obstruction and does not transform the ciliary rubber clearance. With the partial turbinectomy technique, the results derived were comparable to those of outcomes with the radiofrequency organization ablation method <1, 17>.
Salzano etal. Enrolled four groups of patients each treated with radiofrequency, high-frequency electrocautery treatments, and lower partial turbinotomy to reduce the hypertrophied lower turbinates. They show that the partial inferior sleep turbinectomy is the best an approach of treatment, due to the fact that it does not cause damage come the nasal mucosa or basic sensibility nerves <18>.
In the 1996, the microdebrider was an initial used through Davis and Nishioka to remove both medial and also inferior redundant mucosal tissue and also hypertrophied cavernous sinusoid that the worse turbinate and the anterior head region of the inferior turbinate, up the superficial layer come the periosteum <19>.
Generally, if the microdebrider-assisted turbinoplasty is restricted to the decongestion that the turbinates only, the patience undergoes local anesthesia through vasoconstrictive drugs to create a big ischemia preventing intraoperative bleeding. General anesthesia is essential in the event that a septal or paranasal sinus surgical procedure is additionally associated. In our experience, the neighborhood anesthesia is performed making use of soaked gauzes with Xylocain hydrochloride 5% and naphazoline 0.02% set on the nasal floor and on the medial wall of the inferior turbinate. We have actually left the infiltration the the turbinate and also given the feasible neurovegetative complications described by Ravikumar etal. <20>.
This procedure is perform under the endoscopic guidance making use of an 0° endoscope 4-mm diameter. The microdebrider is a device that covers a handpiece on i beg your pardon is positioned a rotating blade protected by a blunt end that sucks and removes the hypertrophic tissue. The surgeon moves the blade of the microdebrider, with 2300–3000 rev/s speed of oscillation, along the worse turbinate from posterior come anterior an ar and with constant suction. It is said to proceed in posteroanterior direction to achieve a clean field, complimentary of blood. The timing of surgery vital to achieve the procedure is around 1–2min long for every nasal cavity <3, 20>. At the finish of the surgery, sleep packing of change length in between 8 and 10cm space placed.
Nasal pack are supplied to prevent postoperative bleeding and to fill the dead space inside the sleep cavity <21>, whereby it remains only for 48h and does not adjust the sensible recovery of the mucosa <3>. The patient is advised to instill sleep drops containing vitamin A and also Vaseline oil for around a month after surgical procedure <3>.
Microdebrider technique is largely discussed since of its supposed interference on mucociliary clearance.
According come Lee and Lee <21>, the microdebrider reasons minimal mucosal damage that go not considerably modify the ciliary mucus transport time. In fact, the whole respiratory epithelium of the sleep cavities, and also not just the mucosa the the inferior turbinate, is responsible because that this physiological mechanism.
According come a study conducted by our college Clinic in the 2012, the microdebrider walk not damage the respiratory epithelium, yet rather engendered its regeneration. Studies performed on pet models have presented that basal cells move the ceiling mucosa forward after a mechanically injury. The cell undergo transient squamous metaplasia, and then they identify both goblet and also ciliated cells. This system has also been prove in human being nasal cavities. The debridement of the mucosa leader to an advancement in sleep obstruction, rhinorrhea, hyposmia, headaches, snoring, and postnasal drip. It is never associated with aftermath such as dryness, crusts, or nasal irritation or with change of mucosal role <3>.
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According to a study performed by valve etal. <22>, the use of the microdebrider technique allowed a success of 93% and only 17 patients presented momentary complications such together bleeding, crusting, and synechia <21>. Lee and also Lee have demonstrated, v a 2006 study, the the use of the microdebrider is an ext effective than the group of patient who have been treated through coblation in obstructive symptomatology and also in reduce the volume of the mucosa the the head of the inferior turbinate 12months after the treatment <21>. It has been defined as the best technique for the treatment of worse turbinates hypertrophy <3>.