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Microdebrider-assisted versus laser-assisted turbinate reduction: comparison of improvement in nasal airway according to type of turbinate hypertrophy.

Abstract

A case-control study was conducted at our secondary referral hospital to compare the efficacy of microdebrider-assisted turbinate reduction (MATR) with laser-assisted turbinate reduction (LATR) and to evaluate their efficacy according to types of hypertrophic inferior turbinates. All patients who underwent only inferior turbinate surgery for refractory nasal obstruction were included. The required minimum follow-up period was 3 months postoperatively. Thirty-seven patients were enrolled in this study--22 in the MATR group and 15 in the LATR group. The patients were subclassified into mucosal (n = 14) and bone (n = 23) hypertrophy groups. Subjective (visual analogue scale) and objective (endoscopic score) assessments were performed prior to surgery and 3 months after surgery. Generally, the visual analogue scale and endoscopic score were significantly improved after surgery, in both the MATR and the LATR groups. In the MATR group, the visual analogue scale and endoscopic score improved regardless of type of hypertrophy. However, in the LATR group, these measurements improved only in cases with mucosal hypertrophy. We conclude that both MATR and LATR are good surgical techniques in patients with chronic hypertrophic inferior turbinates who have substantial nasal obstruction. However, MATR is superior to LATR, especially in cases with bone hypertrophy.

Introduction

Chronic hypertrophy of the inferior turbinate can result in nasal obstruction, which is a common complaint encountered in the practice of rhinology. Over the years, various surgical techniques have been introduced to reduce hypertrophic inferior turbinates, with the goal of increasing nasal patency and preserving the mucosa. Recently, many studies have demonstrated that microdebrider-assisted turbinate reduction (MATR) is superior to other techniques for the surgical treatment of hypertrophic inferior turbinates. (1-6)

Cellular hyperplasia, tissue edema, and vascular congestion are the main contributors to hypertrophic inferior turbinates, but bony enlargement can also be a contributing factor. (7-10) Because each surgical technique has its own mechanisms, it is important for surgeons to understand the underlying pathology of hypertrophic inferior turbinates, to understand the characteristics of each surgical technique, and to select the proper technique for each patient based on the patient's type of hypertrophic inferior turbinates.

To our knowledge no clinical study has been conducted to compare MATR with laser-assisted turbinate reduction (LATR) for hypertrophic inferior turbinates and to compare their efficacy in mucosal and bony hypertrophy. That is the aim of this study.

Patients and methods

Informed consent was obtained from all patients using a customized patient information leaflet and consent form. We did not have formal ethics review committees in the hospital where the study was designed, but the Declaration of Helsinki was followed during data collection and analysis.

Setting and participants. This study was performed at the Otolaryngology Department of a secondary referral hospital. All patients whose refractory nasal obstruction resulted from chronic hypertrophy of the inferior turbinates were candidates for inclusion. They all had symptoms and signs of chronic nasal obstruction related to hypertrophic inferior turbinates that were not responding to medical treatments--including topical corticosteroids, antihistamines, and decongestants--during the preceding several months. The required minimum follow-up period was 3 months postoperatively.

Thirty-seven patients (25 male, 12 female) were enrolled (mean age [+ or -] standard deviation [SD]: 28.8 [+ or -] 9.4 years; range: 15 to 52 years). Patients were subclassified into mucosal (n = 14) and bony (n = 23) hypertrophy groups.

Participants underwent a complete nasal airway evaluation that included a thorough history of medical therapy and a physical examination with a nasal speculum, endoscopy, and a radiologic study. They were excluded if any of the following criteria were present: (1) a history of sinus or nasal surgery, (2) nasal septal deviation, (3) nasalpolyps or tumors, (4) chronic sinusitis resulting in chronic nasal obstruction, (5) adenotonsillar hypertrophy relating to chronic nasal obstruction, (6) any simultaneous nasal or sinus surgery, (7) any simultaneous adenotonsillar surgery, (8) unwillingness to undergo surgery, or (9) unwillingness to participate in follow-up for a minimum of 3 months.

In both subgroups, after a 10% lidocaine cottonoid was packed into the nasal cavity for 1 to 3 minutes, the patients whose subjective nasal patency was improved by 50% or more were classified into the mucosal hypertrophy group, and other patients were classified into the bony hypertrophy group.

Surgical procedures. All surgical procedures were performed by one surgeon (DHL) in the same setting. MATR and LATR were performed under direct visualization via a straight (4 mm, 0[degrees]) endoscope (Karl Storz; Tuttlingen, Germany) under local infiltrative anesthesia with 2% lidocaine and 1:100,000 epinephrine. Patients were in a semi-sitting position.

For MATR, a vertical incision was made with a number 15 scalpel blade. A submucosal pocket was made with a narrow Freer periosteal elevator. Excessive submucosal tissue was removed with a straight, 4-mm microdebrider tip with a cutting blade (Medtronic Xomed; Minneapolis) at 2,000 to 3,000 rpm. In cases of bony hypertrophy, more aggressive resection was accomplished by grinding the hypertrophic concha.

For LATR, a C[O.sub.2] laser (Sharplan; Tel Aviv, Israel) was set to a continuous super-pulse mode at a setting of 7 watts and was focused on the tissue in the noncontact mode. Under endoscopic visualization, 4 to 5 parallel laser stripes were made in a posterior-to-anterior direction along the entire length of the inferior turbinate, leaving islands of intact mucosa. If necessary, multiple laser spots were made on the head of the inferior turbinate. After both procedures, light nasal packs were placed for 1 day.

Outcome criteria. The surgical outcomes for both procedures were evaluated with respect to two parameters: a subjective outcome measure, which was a visual analogue scale (VAS) of nasal obstruction, and an objective outcome measure, which was an endoscopic finding of nasal patency. Both evaluations were performed by one of the authors (EHK) preoperatively and 3 months postsurgically.

A standard VAS, ranging from 0 (no symptoms) to 10 (the most severe symptoms) was used to assess subjective patient complaints. The VAS survey was paper-based and self-administered. Each patient's general satisfaction about postoperative symptom relief was also surveyed.

The endoscopic evaluation was carried out with a straight (4 mm, 0[degrees]) endoscope before the nasal mucosa was decongested. The degree of hypertrophy was classified into 3 endoscopic scores (ES) according to the turbinate width/engorgement:

* Grade 1: inferior turbinate fully retracted;

* Grade 2: inferior turbinate engorgement filling half of the nasal fossa; and

* Grade 3: inferior turbinate engorgement reaching the nasal septum.

Statistics. All statistical analyses were performed using the SPSS software (SPSS, Inc.; Chicago). Comparison in each group was evaluated with the Wilcoxon signed rank test, and comparison between the two groups was evaluated with the Mann-Whitney U test.

Results

Improvement of symptoms. In the MATR group, the overall mean ([+ or -] SD) preoperative VAS for nasal obstruction was 8.5 [+ or -] 1.1, and it significantly improved to 3.2 [+ or -] 1.5 after surgery (p = 0.000) (table 1). Of the 22 patients in this group, 19 (86.4%) answered that they were satisfied with the result of the operation. In the LATR group, the overall preoperative VAS for nasal obstruction was 8.6 [+ or -] 1.1, and it significantly improved to 4.7 [+ or -] 1.9 after surgery (p = 0.001) (table 1). Of the 15 patients in this group, 9 (60.0%) answered that they were satisfied with the result of the operation.

Improvement of nasal patency. In the MATR group, the overall preoperative ES was 2.8 [+ or -] 0.4, and it significantly improved to 1.2 [+ or -] 0.4 after surgery (p = 0.000) (table 2). In the LATR group, the overall preoperative ES was 2.9 [+ or -] 0.3, and it significantly improved to 1.6 [+ or -] 0.7 after surgery (p = 0.001) (table 2).

Improvements according to type of hypertrophy. Table 3 summarizes the improvements in VAS and ES for patients in the mucosal and bony hypertrophy subgroups. In the MATR group, there was no significant difference in the degree of postoperative improvement in the VAS and ES (p = 0.278 and p = 0.342, respectively). VAS and ES improved postsurgically regardless of the type of hypertrophy. The patient satisfaction rates for the bony and mucosal hypertrophy subgroups in the MATR group were 81.3 and 100%, respectively (p = 0.265).

In the LATR group, there were significant differences in the degree of postoperative improvement in the VAS and ES between the bony and mucosal hypertrophy subgroups (p = 0.002 and p = 0.041, respectively). VAS and ES were significantly improved after LATR in the mucosal hypertrophy subgroup, but only a slight improvement was seen in the bony hypertrophy subgroup; this difference did not reach statistical significance (p = 0.054 for VAS and p = 0.063 for ES). Patient satisfaction rates for the bony and mucosal hypertrophy subgroups were 28.6 and 87.5%, respectively (p = 0.025).

Adverse effects. No adverse effects related to the surgical techniques were seen in this study except for early postoperative bloody oozing in 5 patients in the MATR group, which was easily resolved by additional intranasal packing. Some crusting occurred in 6 patients in the MATR group and 5 in the LATR group in the early healing period, but it resolved within 1 to 1.5 months postoperatively.

Discussion

Recently, many surgical techniques and instruments have been developed for the surgical treatment of hypertrophic inferior turbinates to preserve the mucosa and to reduce postoperative complications. The mechanisms by which MATR achieves its results differ from those by which LATR achieves its results. Therefore, MATR can be used both on the submucosal and bone tissue of the inferior turbinate while LATR, together with radiofrequency, can be used only on submucosal tissue (figure).

Recent studies suggest that MATR is superior to other techniques, such as submucosal electrocautery, (1) traditional submucous turbinectomy, (2) outfracture/ lateralization, (3) and radiofrequency. (5-7) However, no study until this one has compared postoperative results according to the underlying pathology of hypertrophic inferior turbinates.

Kizilkaya et al point out that the ideal turbinate surgery should be limited to the submucosal tissue and the bony concha. (7) The reduction of bony concha can create more space in the nasal cavity, whereas surgery limited to the submucosal tissue may create scarring, especially in cases in which bone enlargement is present. This is why surgeons should know the working mechanisms of various surgical techniques and select the proper one according to underlying pathologies. Kizilkaya et al also emphasize the importance of the reduction of bony concha, but they do not analyze their results based on the type of hypertrophic inferior turbinate. (7)

Our results demonstrate that there is no significant difference in surgical outcomes between MATR and LATR when the type of hypertrophy is not taken into account, which is consistent with Kizilkaya et al's findings. (7) However, this result should not lead to the erroneous conclusion that surgical techniques limited to the submucosal tissue (LATR, as in the present study, or radiofrequency (7)) can produce the same surgical outcomes as techniques that reduce both submucosal and bony turbinate (MATR). If more cases of mucosal hypertrophy than bony hypertrophy are studied, the difference in surgical outcomes between the two surgical techniques is not evident. This is the why an analysis according to types of inferior turbinate hypertrophy was needed. In the present study, LATR was found to improve VAS and ES in mucosal hypertrophy but not in bony hypertrophy.

[FIGURE OMITTED]

The major limitation of our study involved the criteria used for types of hypertrophy. Unfortunately, we used subjective criteria as one outcomes measurement because computed tomography (CT) scans were not obtained in some patients. Our subclassification method was not validated, but we think it is useful because "obstruction" is itself a subjective description; perhaps a subjective method is preferable for measuring a subjective parameter. Some evidence supports this, as CT scan findings correlate to some degree with the severity of nasal-specific symptomatology, but CT findings alone do not fully explain nasal-specific symptoms. (11)

The second limitation of this study was our distinguishing between bony and mucosal hypertrophy--a distinction that has not yet been established. This was why we introduced the subjective criteria, based on whether the obstructive symptom was improved by the mucosal shrinkage.

The third limitation of this study was the small number of enrolled patients. Because patients who had only chronic hypertrophic inferior turbinates were included and those with other concomitant nasal or sinus diseases were excluded, it was impossible to enroll enough subjects during the limited duration of the study.

In conclusion, we found that MATR and LATR generally can improve subjective (VAS) and objective (ES) parameters of nasal obstruction postoperatively. However, MATR improved these parameters significantly in both bony and mucosal hypertrophies, whereas LATR did not improve both parameters in bony hypertrophy.

Surgeons should keep in mind that MATR, which can be used on submucosal as well as bony turbinates, may result in better outcomes in some cases of hypertrophic inferior turbinates, especially in patients with bony hypertrophy.

References

(1.) Joniau S, Wong I, Rajapaksa S, et al. Long-term comparison between submucosal cauterization and powered reduction of the inferior turbinates. Laryngoscope 2006;116(9):1612-16.

(2.) Chen YL, Liu CM, Huang HM. Comparison of microdebrider-assisted inferior turbinoplasty and submucosal resection for children with hypertrophic inferior turbinates. Int J Pediatr Otorhinolaryngol 2007;71(6):921-7.

(3.) Chen YL, Tan CT, Huang HM. Long-term efficacy of microdebrider-assisted inferior turbinoplasty with lateralization for hypertrophic inferior turbinates in patients with perennial allergic rhinitis. Laryngoscope 2008;118(7):1270-4.

(4.) Yanez C, Mora N. Inferior turbinate debriding technique: Ten-year results. Otolaryngol Head Neck Surg 2008;138(2):170-5.

(5.) Liu CM, Tan CD, Lee FP, et al. Microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty. Laryngoscope 2009; 119(2):414-18.

(6.) Lee JY, Lee JD. Comparative study on the long-term effectiveness between coblation-and microdebrider-assisted partial turbinoplasty. Laryngoscope 2006;116(5):729-34.

(7.) Kizilkaya Z, Ceylan K, Emir H, et al. Comparison of radiofrequency tissue volume reduction and submucosal resection with microdebrider in inferior turbinate hypertrophy. Otolaryngol Head Neck Surg 2008;138(2):176-81.

(8.) Berger G, Gass S, Ophir D. The histopathology of the hypertrophic inferior turbinate. Arch Otolaryngol Head Neck Surg 2006;132(6): 588-94.

(9.) Farmer SE, Eccles R. Chronic inferior turbinate enlargement and the implications for surgical intervention. Rhinology 2006;44(4): 234-8.

(10.) Akoglu E, Karazincir S, Balci A, et al. Evaluation of the turbinate hypertrophy by computed tomography in patients with deviated nasal septum. Otolaryngol Head Neck Surg 2007;136(3):380-4.

(11.) Bhattacharyya N. A comparison of symptom scores and radiographic staging systems in chronic rhinosinusitis. Am J Rhinol 2005;19 (2):175-9.

Dong-Hee Lee, MD, PhD; Eun Hye Kim, MD

From the Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul.

Corresponding author: Dong-Hee Lee, MD, PhD, Department of Otolaryngology-Head and Neck Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, #65-1 Geumo-Dong, Uijeongbu City, Gyeonggi-Do, 480-717, Korea. E-mail: leedh0814@ catholic.ac.kr

Previous presentation: Some of the information in this article was presented as a poster at the 16th World Congress of the International Society for Laser Surgery and Medicine; Tokyo, Japan; Sept. 7-10, 2005).
Table 1. Comparison of visual analogue scale (VAS) scores
of nasal obstruction in the MATR and LATR groups before
and after surgery (mean [+ or -] SD)

         Preoperative      Postoperative     p Value
             VAS                VAS

MATR   8.5 [+ or -] 1.1   3.2 [+ or -] 1.5    0.000
LATR   8.6 [+ or -] 1.1   4.7 [+ or -] 1.9    0.001

Table 2. Comparison of endoscopic scores (ES) in the
MATR and LATR groups before and after surgery (mean
[+ or -] SD)

         Preoperative      Postoperative     p Value
              ES                 ES

MATR   2.8 [+ or -] 0.4   1.2 [+ or -] 0.4    0.000
LATR   2.9 [+ or -] 0.3   1.6 [+ or -] 0.7    0.001

Table 3. Summary of visual analogue scale (VAS) scores of nasal
obstruction and endoscopic scores (ES) in the bone and mucosa
subgroups before and after surgery (mean [+ or -] SD)

                                     Bone         p Value
                                   (n = 16)

MATR       Preoperative VAS    8.2 [+ or -] 1.2
(n = 22)                                           0.000
           Postoperative VAS   3.3 [+ or -] 1.5
           Preoperative ES     2.8 [+ or -] 0.4
                                                   0.000
           Postoperative ES    1.2 [+ or -] 0.4

                                     Bone         p Value
                                   (n = 7)

LATR       Preoperative VAS    8.3 [+ or -] 1.1
(n = 15)                                           0.054
           Postoperative VAS   6.1 [+ or -] 0.9
           Preoperative ES     2.9 [+ or -] 0.4
                                                   0.063
           Postoperative ES    2.0 [+ or -] 0.8

                                    Mucosa        p Value
                                   (n = 6)

MATR       Preoperative VAS    9.2 [+ or -] 0.8
(n = 22)                                           0.027
           Postoperative VAS   3.0 [+ or -] 1.8
           Preoperative ES     3.0 [+ or -] 0.0
                                                   0.020
           Postoperative ES    1.2 [+ or -] 0.4

                                    Mucosa        p Value
                                   (n = 8)

LATR       Preoperative VAS    8.9 [+ or -] 1.1
(n = 15)                                           0.011
           Postoperative VAS   3.5 [+ or -] 1.6
           Preoperative ES     3.0 [+ or -] 0.0
                                                   0.008
           Postoperative ES    1.3 [+ or -] 0.5
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Title Annotation:ORIGINAL ARTICLE
Author:Lee, Dong-Hee; Kim, Eun Hye
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:9SOUT
Date:Nov 1, 2010
Words:2810
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