Introduction
Inferior turbinate hypertrophy is one of the most common causes of nasal obstruction, and in most cases results from allergic rhinitis or nonallergic rhinitis. While common, the exact prevalence of inferior turbinate hypertrophy is unknown. A large study of 1,900 patients with sinonasal complaints found a 77% incidence of turbinate hypertrophy in patients with severe Nasal Obstruction Symptom Evaluation (NOSE) scores. First-line treatment of inferior turbinate hypertrophy is medical, including intranasal corticosteroids, antihistamines, and immunotherapy. Patients with inferior turbinate hypertrophy refractory to medical management are candidates for surgical intervention. There are numerous approaches to achieve inferior turbinate reduction and alleviate symptoms. Inferior turbinate reduction is one of the most commonly performed procedures by otolaryngologists, with an average annual increase of 3.8%.
With the rise of minimally invasive options, in-office procedures have become increasingly popular for addressing inferior turbinate hypertrophy. These procedures carry the advantage of reduced cost, patient convenience, and avoidance of anesthesia. From 2000 to 2015, the number of turbinate reduction procedures by Medicare providers increased from 27,670 to 48,285. During this time, in-office radiofrequency ablation increased by 121.6%, and turbinate submucosal resection increased by 260.1%.
This chapter explores the various in-office procedures available for managing inferior turbinate hypertrophy.
Anatomy and Physiology
The inferior turbinates are paired structures in the inferior nasal cavity that span from the nasal vestibule to the choanae posteriorly. They are composed of bone, mucoperiosteum, erectile tissue, and mucosa. The inferior turbinate is adjacent to the perpendicular plate of the ethmoid bone and nasal maxilla. The mucosa consists of pseudostratified respiratory epithelium, which contains ciliated columnar cells, goblet cells, basal cells, and other immune cells. The inferior turbinate mucosa and submucosa contain glands and have a rich blood supply that play a role in warming and humidifying inspired air and trapping particulate matter. The nose warms inspired air to 37°C and can raise the humidity of inspired air to approximately 85%, which facilitates gas exchange in the lower airway.
The inferior turbinates contain both sympathetic and parasympathetic innervation. The trigeminal nerve provides sensation to the nasal cavity, including the perception of nasal airflow. Blockage of these receptors can result in the sensation of nasal obstruction. Sympathetic stimulation is responsible for vasoconstriction and decreased airway resistance, while parasympathetic stimulation results in vasodilation and glandular secretions. The submucosal cavernous plexus expands in response to triggering factors, such as allergies, hormones, and infection. Excessive and chronic stimulation can lead to permanent hypertrophy. The nasal cycle refers to asymmetric changes in vasodilation/vasoconstriction of the nasal mucosal large veins. The cycle typically lasts between 50 minutes and 4 hours and is present in at least 80% of the population. It is important to note that while the resistance to airflow alternates between the nasal cavities, the combined nasal resistance and total airflow do not fluctuate.
The inferior turbinate is also a critical component of the internal nasal valve, which is bordered medially by the superior septum, laterally by the caudal aspect of the upper lateral cartilage, and posteriorly by the head of the inferior turbinate. The angle between the superior septum and upper lateral cartilage is typically 10 to 15 degrees. The nasal valve is the narrowest part of the nasal airway and has the greatest resistance to airflow. Poiseuille law states that airflow resistance is related to the inverse of the radius to the fourth power, which means minimal narrowing of the internal nasal valve can contribute significantly to nasal obstruction.
The inferior turbinate is supplied by the inferior turbinate artery, a branch of the posterior lateral nasal artery that arises from the sphenopalatine artery and anastomoses with the ethmoidal arteries and descending palatine artery.
Patient Evaluation
Before considering in-office procedures for inferior turbinate hypertrophy, a comprehensive patient evaluation is crucial. This should include:
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Medical History
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A detailed history should be obtained. Specifically, the clinician should ask about laterality of symptoms, onset, and seasonal variation. For patients with a menstrual cycle, fluctuations in estrogen levels and pregnancy may also contribute to nasal obstruction. The clinician should inquire about a history of nasal trauma, as this can cause structural abnormalities that lead to obstruction. Additional symptoms may include rhinorrhea and/or postnasal drainage. The presence of facial pain or pressure, olfactory dysfunction, or recurrent sinus infections may indicate chronic sinusitis. Itching, sneezing, and seasonal fluctuation may indicate allergic component. The medical interview should also include detailed past medical history, including any prior nasal procedures or surgery, medication review, and social history.
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Physical Examination
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To evaluate the degree of nasal obstruction, assess for anatomical variations, and determine the severity of turbinate hypertrophy.
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Nasal Endoscopy
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Nasal endoscopy is used to visualize the nasal cavity and assess signs of hypertrophy and mucosal changes. There are several grading systems to describe the degree of inferior turbinate hypertrophy. Camacho et al. describe a 1-to-4 grading system: When the inferior turbinate occupies 0% to 25% of total airway space, it is grade 1; grade 2 is 26% to 50%, grade 3 is 51% to 75%, and grade 4 is 76% to 100%.
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Nasal manometry can objectively measure the degree of obstruction from inferior turbinate hypertrophy by measuring the differential pressure between the anterior and posterior nasal cavity. Anterior rhinomanometry is quick and reproducible and provides an objective measure of the volume of nasal sections. However, it is not readily available in most clinics. It is therefore most often used in research studies and pediatric populations.
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Patient Selection and Setup
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Patient Selection
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Initial attempts at medical management are warranted in a majority of patients. Medical management should be tailored to the underlying often includes saline rinses, topical steroids, topical antihistamines, decongestants, and, in some cases, allergen immunotherapy.
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Patients with persistent symptoms despite appropriate medical therapy may benefit from procedural intervention. Ideally, patients selected for in-office procedures are comfortable with minimal or oral sedation and do not have excessive anxiety or fear of needles and injections. Patients with significant medical comorbidities and on antiplatelet and anticoagulation medications may not be appropriate for in-office procedures. Insurance coverage of in-office procedures can vary greatly and should be discussed prior to treatment.
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Patients should be counseled on the risks of in-office nasal procedures, which are infrequent.
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Scott et al. describe a series of 315 patients undergoing in-office nasal procedures and found that procedures were stopped early in 2.5% of patients due to either tolerance, bleeding, or vasovagal response. Included in this series were 166 turbinoplasties and 74 endoscopic sinus surgeries.
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Setup
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Procedures should be performed in a room equipped with a comfortable chair that can recline and with enough room for the surgeon, an assistant, and any necessary equipment. Many inferior turbinate procedures can be performed either with a headlight under direct visualization or with an endoscope.
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If patients are sedated, they should be monitored with pulse oximetry and possibly cardiac monitoring. Emergency equipment should include oxygen, a defibrillator, and medications such as epinephrine and naloxone.
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Nasal anesthesia should begin with topical vasoconstrictive agents, such as phenylephrine or oxymetazoline, and topical anesthesia, typically with 4% lidocaine. Local injection is then performed with lidocaine with epinephrine.
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Patients should be monitored adequately following completion of the procedure prior to leaving the office. If narcotics or sedating medications were taken, they should be advised against driving after the procedure.
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Surgical Techniques
Many options exist for inferior turbinate reduction ( Table 22.1 ). In-office turbinate reduction with extensive resection involving cold instruments may not be as well tolerated in awake patients and will not be discussed extensively in this chapter. Other options include submucosal resection with microdebrider or radiofrequency ablation ( Fig. 22.1 ), electrocautery, and laser-assisted inferior turbinate reduction.
Table 22.1
Description of Currently Available Techniques for Inferior Turbinate Reduction
| Technique | Description | Advantages | Disadvantages |
|---|---|---|---|
| Turbinectomy | Total, partial, or submucosal resection using cold instruments | Crusting, atrophic rhinitis | |
| Microdebrider | Submucosal resection using microdebrider | Versatility, familiarity with technique | Bleeding, pain |
| Radiofrequency | Use of radio waves to generate heat and cause tissue fibrosis and shrinkage | Easy to use, comparable results | Limited effect on bone |
| Electrocautery | Electrical current used to ablate inferior turbinate tissue. Includes monopolar, bipolar, and diathermy electrode | Widely available, less bleeding | |
| Laser | Use of light energy to ablate tissue. Includes CO 2 , KTP | Cost, nonmucosal sparing |
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