1
Introduction
The inferior turbinate is the largest of the three paired turbinates and plays a large role in humidifying and filtering air, as well as directing airflow through the nose. The inferior turbinate consists of the turbinate bone covered with erectile soft tissue and nasal respiratory epithelium. Inferior turbinate hypertrophy can be caused by generalized nasal mucosal disease in allergic and nonallergic rhinitis, as well as compensatory hypertrophy due to long-standing septal deviation.
2
Indications, Contraindications, and Alternative Treatment Options
Medical treatments such as topical corticosteroid sprays and antihistamines are usually the first-line therapy. However, in patients who have enlarged inferior turbinates who have failed medical therapy, surgical reduction of the hypertrophic inferior turbinate has been proven to improve nasal obstruction. In the surgical treatment of obstructive sleep apnea, sometimes multilevel surgical treatment is employed, including relief of nasal obstruction via inferior turbinate reduction. In some patients, inferior turbinate reduction is performed to relieve nasal obstruction to allow for better tolerance of continuous positive airway pressure machine use. Contraindications include patients who are not surgical candidates. Alternatives include medical management alone and observation.
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Anesthesia
Inferior turbinoplasty could be performed under local or general anesthesia. In the clinic, local anesthesia could be achieved using topical oxymetazoline and lidocaine, often by placing a cottonoid pledget soaked in the medication, followed by injection of 1% lidocaine with 1:100,000 epinephrine. The patient is often positioned in the exam chair in an upright to slightly reclining position. Under general anesthesia, the patient is positioned in the beach chair position with the head elevated approximately 15 degrees. Injection of 1% lidocaine and 1:100,000 epinephrine is often performed to assist with hemostasis, as well as to enhance the effects of radiofrequency ablation by providing an ionic medium.
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Turbinate Reduction Techniques
There are multiple techniques for turbinate reduction. In 1895, total and partial turbinectomy was first described for surgical treatment of nasal obstruction. However, as a result of the adverse effects of turbinectomy, such as postoperative bleeding, synechiae, and empty nose syndrome, submucosal resection turbinoplasty rose in popularity, which was first proposed by Mabry in 1984. Some of the most common techniques include microdebrider-assisted turbinoplasty and radiofrequency ablation turbinoplasty, which target reduction of the submucosal erectile tissue of the turbinate with minimal damage to the respiratory mucosa. Turbinoplasty may be performed under rigid nasal endoscopy or direct visualization.
The microdebrider-assisted turbinoplasty technique is performed by making an incision on the anterior-inferior aspect of the inferior turbinate and inserting the 2-mm inferior turbinate blade microdebrider to submucosally remove tissue ( Fig. 25.1 ). The incision could be made using a scalpel or by using the inferior turbinate blade itself. Care must be taken such that the microdebrider blade does not exit the inferior turbinate mucosa. Attention should also be given to reduce the anterior bulk of the inferior turbinate, where obstruction often occurs near the internal nasal valve.
