The turbinates in nasal and sinus surgery: a consensus statement. (Guest Editorial).

A panel to discuss various issues concerning surgery of the middle and inferior turbinates in patients with nasal and sinus disease was convened by the American Rhinological Society during the Combined Otolaryngological Spring Meetings in May 2001. The panel was chaired by the lead author(D.H.R.) and made up of the other authors listed above. What follows are some of the highlights of the presentations and the panelists' conclusions and consensus recommendations.

Routine resection of the middle turbinates remains controversial, although most otolaryngologists agree that under certain circumstances, surgical manipulation is necessary. There is little doubt that in some fashion, the middle turbinates influence every operation that is performed on the paranasal sinuses for the treatment of chronic infection. Therefore, the surgeon must be able to recognize their anatomic variations.

In a typical case, a middle turbinate is convex medially, which is ideal because it allows for access to the middle meatus. In atypical cases, a paradoxical middle turbinate is convex laterally, which often results in a narrowing of the middle meatus. The formation of a concha bullosa is the result of pneumatization of a middle turbinate; the resulting increase in the volume of the middle turbinate causes a decrease in the volume of the middle meatus. As is the case with a paradoxical middle turbinate, development of a concha bullosa is not necessarily a pathologic process; it can occur in the presence of normal paranasal sinus function. Finally, in some patients, the appearance of the middle turbinate might be radically altered by previous surgery.

Choice of management options

Middle turbinates. There are a number of ways in which the surgeon can address the middle turbinates. The choice should be based on individual patient variables and on the experience of the surgeon.

One option is resection. Many authors recommend partial rather than total resection to limit the possibility of skull base injury and to maintain the anatomic landmark. The concha bullosa can be managed in a variety of ways, but the classic method is resection of the lateral wall (lateral lamella). Ideally, such a procedure will widen the middle meatus while maintaining the landmark.

Another option is to control the synechial formation between the middle turbinate and the nasal septum--a procedure sometimes referred to as Bolgerization. (1) This technique prevents lateralization of the middle turbinate. Another way to accomplish the same goal is to place an absorbable through-and-through mattress suture to hold both middle turbinates to the septum.

Inferior turbinates. The inferior turbinates pose problems of their own. Before surgery on an inferior turbinate is undertaken, a trial of medical management is mandatory. This usually includes an antihistamine and decongestant, treatment for nasal allergy (possibly including the use of nasal cromolyn), and immunotherapy. In addition, a systemic or intranasal steroid should be tried.

Should medical management fail, the clinician has several options. The many types of surgery for inferior turbinate enlargement can be broadly classified into three categories: (1) simple mechanical means, such as crushing or lateral fracturing, (2) destructive procedures, such as electrocautery or laser vaporization, which reduce the volume of the turbinate, and (3) actual resection procedures, such as submucosal resection, partial resection, trimming of the turbinates, or inferior turbinoplasty.

The utility of the laser in the management of inferior turbinate enlargement is largely grounded in the fact that it can be used effectively in the office setting. Laser treatment can involve submucosal diathermy with the neodimium:yttrium-aluminum-garnet (Nd:YAG) laser, photocoagulation with the potassium-titanyl-phosphate (KTP) laser, or vaporization with the carbon dioxide ([CO.sub.2]) laser in superpulse mode.

Radiofrequency ablation with a variety of instruments is also available, as is argon plasma surgery. One advantage of these two procedures is that they carry little risk of bleeding.

When formal surgery is required, submucosal resection, extramucosal electrocautery, and radiofrequency ablation are all effective, as is inferior turbinoplasty. The latter can be performed endoscopically with a microdebrider, which results in less operative bleeding and more precise removal of tissue.

Conclusions and consensus

The panel members agree that middle turbinate resection, either subtotal or total, might be indicated for patients who have a paradoxically bent middle turbinate, a concha bullosa, or significant polyposis, particularly patients who have eosinophilic mucinous rhinosinusitis or allergic fungal sinusitis. We also agree that partial inferior turbinate resection is also indicated when the inferior turbinate is part of the problem. Complications of subtotal middle turbinate resection in and of itself appear to be few and rarely severe.

The panelists feel that the middle turbinate should not be sacrificed without a satisfactory reason, and we believe that reduction of the inferior turbinate should be conservative as well. It is our opinion that the more that one turbinate is resected, the less the other should be manipulated. We advocate that the simultaneous removal of both the middle and inferior turbinates should not be performed for the treatment of non-neoplastic disease.

The excess removal of turbinate tissue might lead to empty-nose syndrome. Excess resection can lead to crusting, bleeding, breathing difficulty (often the paradoxical sensation of obstruction), recurrent infections, nasal odor, pain, and often clinical depression. In one study, the mean onset of symptoms occurred more than 8 years following the turbinectomies (unpublished data, 2001). This finding should prompt the surgeon to be conservative in the management of the turbinates but willing to do what is necessary to achieve the desired result.

Reference

(1.) Bolger WE, Kuhn FA, Kennedy DW. Middle turbinate stabilization after functional endoscopic sinus surgery: The controlled synechiae technique. Laryngoscope 1999;109:1852-3.

From the Department of Otolaryngology--Head and Neck Surgery, University of Southern California Keck School of Medicine, Los Angeles (Dr. Rice); the Department of Otolaryngology--Head and Neck Surgery, Mayo Clinic, Rochester, Minn. (Dr. Kern); and the Department of Otolaryngology--Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas (Dr. Marple and Dr. Mabry). Dr. Friedman is in private practice in St. Louis.

Reprint requests: Dale H. Rice, MD, Department of Otolaryngology--Head and Neck Surgery, University of Southern California Keck School of Medicine, 1200 N. State St., Box 795, Los Angeles, CA 90033. Phone: [phone]; fax: [phone]; e-mail: [e-mail]