Surgery of the Turbinate

Introduction

Surgical therapy for the inferior or middle turbinates is most commonly indicated in the setting of turbinate hypertrophy and chronic nasal obstruction that has failed to improve with medical therapy. Surgery of the turbinate may be an isolated stand-alone procedure or carried out in conjunction with a nasal septoplasty in which compensatory inferior turbinate hypertrophy may be present on the concave side of a significantly deviated septum.

Abnormally large turbinates may be related to anatomic variance or due to pathophysiology, such as rhinitis or rhinosinusitis. The goals of turbinate surgery should include not only the improvement of nasal airflow but also the maintenance of normal physiology. Hence surgery should be performed in a manner that preserves the ability of the turbinate to condition inspired and expired air, assist in mucociliary flow, and sense nasal airflow.

One area of concern in turbinate surgery is overresection of the turbinates. This is theorized, though not proven, to damage the perception of airflow, possibly by disrupting innervation and mucosal surface receptors. This may result in the subjective paradoxical experience of nasal obstruction in an objectively widely patent nasal cavity, otherwise referred to as “empty nose” syndrome. Hence mucosal sparing techniques should be used whenever possible.

Many techniques have been described for reduction of the inferior turbinate, including diathermy, radiofrequency ablation (RFA), partial and complete turbinectomy, submucosal resection, and powered submucosal resection. The last is our preferred method.

Middle turbinate surgery may be necessary as part of a procedure to address nasal airway obstruction in the case of a concha bullosa and may also be necessary as a key complementary component of nasal septoplasty, as a large concha can prevent efforts to correct a septal deviation. In some cases, a large concha bullosa may be dissected to improved access to the uncinate process and ethmoid bulla during sinus surgery.

Key Operative Learning Points

1.
Nasal airflow studies have revealed that the majority of airflow occurs along the middle of the nasal cavity, across the superior surface of the inferior turbinate and body of the middle turbinate into the nasopharynx.
2.
There appear to be marked changes in turbulent flow, negative pressure, and maximum shear stress in patients with turbinate hypertrophy in studies of nasal computational fluid dynamics.
3.
Subjective nasal obstruction may not correlate with objective obstruction. The reverse is also true. Surgery to reduce turbinates in an already objectively patent airway is not likely to benefit patients with subjective obstruction. In such cases, an alternative etiology, such as nasal valve collapse, should be sought. Furthermore, especially in patients who have undergone multiple previous procedures, somatization or psychosocial issues that might contribute to the patient’s complaints should be considered. In these situations, demonstrating to the patient an objectively patent airway, either with acoustic rhinometry or video endoscopy, may be of benefit. In addition, a lack of response to nasal decongestants may also help to convince this patient of the baseline patency of his or her nasal airway.
4.
There are multiple techniques for reduction of the inferior turbinates, but there is no universally accepted best method. Contemporary methods of turbinate reduction should maintain a functional mucosal surface that conditions inspired and expired air and senses airflow.
5.
Overresection of the inferior turbinate mucosa may lead to significant bony exposure with excessive crusting or could place the patient at risk for empty nose syndrome.
6.
The approach to the patient with nasal obstruction should include an assessment of the external nasal framework, inferior turbinates, middle turbinates, and nasal septum.
7.
It is essential to respect the uncinate process and ethmoid bulla during lateral laminectomy of a concha bullosa in order to prevent iatrogenic sinus disease.
8.
Medial laminectomy has been demonstrated to be as effective as lateral laminectomy for aeration of the middle turbinate (i.e., a concha bullosa).
9.
Olfactory epithelium may be more prevalent on the lateral aspect rather than the medial aspect of a concha bullosa.

Preoperative Period

History

1.
History of present illness
- a.
  Is the nasal obstruction fixed or variable? Fixed obstruction may occur in the setting of severe septal deviation or hypertrophy of the inferior turbinate, nasal polyps, or tumor. Variable obstruction may occur due to the same factors already noted in less severe form, such that the nasal cycle and positioning of the patient contribute to further compromise of the nasal airway in varied proportions. Patients in whom obstruction is worse when the patient is supine likely are experiencing an increase in the size of the inferior turbinates due to sinusoidal engorgement, suggesting that turbinate hypertrophy is contributing to obstructive nasal symptoms. Variable obstruction may also be related to the intensity with which air is inspired. Patients with nasal valve collapse may complain of nasal obstruction that is most bothersome during more intense inspiration, such as sniffing or during exercise.
- b.
  Is the nasal obstruction unilateral or bilateral? If unilateral, which side? Unilateral nasal obstruction may be related to the etiologies already described. In some cases septal deviation toward the side of the complaint may be the underlying etiology. However, compensatory hypertrophy of the inferior turbinate contralateral to the side of a septal deviation may also be significant enough that it contributes to a perception of unilateral nasal congestion contralateral to the side of the deviation. In such cases, the obstruction may be more dynamic, with fluctuations in severity related to the nasal cycle. The patient with unilateral nasal obstruction, especially if new and associated with epistaxis, deserves special attention in order to rule out neoplasia as the etiology.
- c.
  What are the aggravating factors? Nasal obstruction that worsens when the patient is supine may be related to turbinate hypertrophy, as noted earlier.
- d.
  What are the alleviating factors? Nasal obstruction that improves with topical decongestants may suggest that turbinate reduction should be a part of the overall surgical strategy, particularly soft tissue submucosal resection. Patients for whom external nasal manipulation has helped (tip elevation, Breathe-Right Strips, nasal cones) may benefit from alternative or complementary techniques that address the external nasal framework and/or nasal valves.
2.
Past medical history
- a.
  Prior or current medical treatment:
  - 1)
    As noted earlier, the use of topical decongestants and the perceived efficacy by the patient give insight into the potential success of turbinate surgery.
  - 2)
    It is important to review the physician-directed medical therapy the patient has completed up to this point. It is prudent to first perform a trial of topical and/or oral therapy, as success with such medications may allow the patient to avoid surgery.
- b.
  Comorbid disorders
  - 1)
    Certain disorders, such as allergic rhinitis, contribute to nasal obstruction due to mucosal edema. Failure to appropriately manage comorbid inflammatory conditions with medication may decrease the long-term efficacy of nasal airway surgical procedures.
  - 2)
    See Box 97.1 for a list of some contributors to nasal obstruction that may require medical therapy in addition to surgical intervention.
    BOX 97.1
    
    Comorbidity Associated With Nasal Obstruction
    1.
    Allergic rhinitis
    
    2.
    Chronic rhinosinusitis
    
    3.
    Mucositis related to chemotherapeutic drugs
    
    5.
    Nasopharyngitis and/or adenoid hypertrophy
    
    6.
    Nonallergic rhinitis
    
    7.
    Rhinitis medicamentosa
    
    8.
    Vasculitis and granulomatous disorders
- c.
  Vasculitis or other inflammatory conditions that affect mucosal integrity
  - 1)
    These patients may require more delicate dissection and resection to prevent tearing and bony exposure. Because of their underlying medical condition, these patients may be at risk for significant crusting.
3.
Surgery
- a.
  Previous turbinate or other nasal airway surgery
  - 1)
    It is important to identify the specific procedures previously performed and to determine the perceived degree and period of efficacy experienced by the patient.
4.
Medications
- a.
  Antiplatelet and anticoagulant medications should be identified. Decisions related to temporary suspension of these medications should be made in consultation with the prescribing physician.
- b.
  Herbal products that might lead to excessive bleeding, such as ginkgo biloba or ginseng, should be discontinued prior to surgery.
- c.
  In patients with rhinitis medicamentosa, discontinuing topical decongestants prior to surgery, with the addition of topical and/or oral steroids as a method to aid in weaning, might help improve efficacy of the topical decongestants used on the day of surgery.

Physical Examination

1.
Observe restful and exaggerated inspiration. This may help to determine if dynamic nasal valve collapse contributes to the patient’s nasal obstruction.
2.
Perform an anterior rhinoscopy. This allows for assessment of the caudal septum and columella as well as the anterior nasal cavity structures, including the nasal valve.
3.
Perform a sinonasal endoscopy. This procedure allows for a more detailed evaluation of the sinonasal cavity and the nasopharynx. Evaluate for concha bullosa, posterior septal deviation or spurs, nasal polyps, nasopharyngeal lesions or tumors, or other pathologic process that may contribute to nasal obstruction.
4.
Examine the oral cavity. This may reveal other causes for generalized airway obstruction and snoring, such as tonsillar hypertrophy. Occasionally antrochoanal polyps will be visible on oropharyngeal examination.

See Table 97.1 for a list of some of the causes of nasal obstruction.

TABLE 97.1

Causes of Nasal Obstruction

Common	Uncommon
Benign tumors	Adenoid hypertrophy
Inferior turbinate hypertrophy	Foreign body
Large concha bullosa	Malignant tumors
Nasal polyps	Septal abscess
Nasal valve collapse	Septal body edema
Septal deviation	Septal hematoma
	Synechiae (postsurgical, posttrauma, or disease-related)

Imaging

When surgery solely for the purposes of relieving nasal obstruction is being considered, imaging is generally not necessary.
In certain situations, a maxillofacial computed tomography (CT) scan may aid in the accurate diagnosis of disorders such as chronic rhinosinusitis, which may contribute to nasal obstruction and other associated symptoms.

Indications

Inferior Turbinate

Nasal obstruction due to hypertrophy of the inferior turbinate

Middle Turbinate

Large concha bullosa causing nasal obstruction
Large concha bullosa with obstruction of the ostiomeatal complex

Contraindications

1.
Medical comorbidities with unacceptable risk for elective surgery
2.
Previous turbinate surgery resulting in adequate objective nasal airway parameters but with subjective nasal obstruction. These patients likely suffer from a lack of sensation (empty nose syndrome) or other disorders, as noted earlier, rather than nasal obstruction.
3.
The presence of sinonasal malignancy should warrant primary treatment of the tumor.

Preoperative Preparation

1.
Institute a trial of medical therapy including management of comorbid disease that could contribute to nasal congestion.
2.
Discontinue medications that could interfere with hemostasis as deemed appropriate via consultation with the prescribing physician.

Operative Period

Anesthesia

Submucosal resection of the turbinates, either with the microdébrider or through-cutting instruments, is best performed under general anesthesia. This optimizes patient comfort and protection of the airway.
Awake sedation may be an option for less invasive procedures associated with minimal risk of hemorrhage, such as submucosal coblation. This may be best performed in the operating theater (monitored anesthesia care) in order to manage the airway optimally in the event of brisk bleeding and/or airway compromise due to the level of sedation.
Local anesthesia may be an option for less invasive procedures associated with minimal risk of hemorrhage, such as submucosal coblation. In this situation, the patient should have full faculty to maintain a sufficient airway in the event of brisk bleeding.

Positioning

The most appropriate position depends on the surgical technique and anesthetic used.
For patients undergoing submucosal resection of the inferior turbinates or middle turbinate surgery, through-cutting instruments or a microdébrider may be used with the patient in the supine position and under general anesthesia.
The beach-chair position may be an option in procedures performed with awake sedation or in-office procedures using local anesthesia.
The sitting position may also be an option for patients having procedures using local anesthesia only.

Perioperative Antibiotic Prophylaxis

Antibiotic prophylaxis is not definitively indicated for turbinate surgery without the use of packing material or splints. If antibiotics are utilized, a first-generation cephalosporin (or clindamycin for penicillin-allergic patients) is appropriate.

Monitoring

No monitoring specific to turbinate surgery is required.

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