Role for Turbinectomy In the Crowded Nasal Airway, Is Empty Nose Syndrome A Reality In These Patients?

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Does Empty Nose Syndrome Occur following turninectomy in patients with a crowded nasal airway? Hoe successful is turbinectomy in relieving nasal obstruction and chronis sinus headaches

Does Empty Nose Syndrome Occur following turninectomy in patients with a crowded nasal airway? Hoe successful is turbinectomy in relieving nasal obstruction and chronis sinus headaches

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  • HI Erika, Sorry for your troubles. For my patients with very narrow noses, turbinectomy has worked over 80% of the time in relieving their nasal obstruction or disabling headaches. That is my experience and I would never suggest that it would apply to you. I am sorry my data doesn't fit for you, you may be very different in your anatomy.
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  • Hello Erika, I am sorry for your troubles and I am aware of how difficult it must be for you. Please understand that I have performed over 200 of these procedures but only in patients who had very narrow airways and in whom the relief was significant in over 80%. These are my findings in the select population I have operated on. These findings may not pertain to you so please do not be offended.
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  • You have to be kidding me. I have ENS from an unconsented turbinectomy, which was added to pad my septoplasty bill. It has destroyed my health and my life. You try one before claiming to know it all!!
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  • 1. Turbinectomy Does Not Cause Empty Nose Syndrome in the Crowded Nasal Airway Rex Moulton-Barrett, M.D., Jory Statner , Natalie Niedzwiedz and Kara Babo Rex Moulton-Barrett, FACS Plastic & Reconstructive Surgery, Otolaryngology - Head & Neck Surgery
  • 2. “ Few Areas of surgical intervention are more controversial than the procedures intended to relief nasal obstruction secondary to hypertrophy of the inferior turbinate ” Elwany S and Harrison R, 1990 J Laryngol and Otol 104, 206-209
  • 3. 1. > 50% pts with nasal obstruction + turbinate hypertrophy fail medical therapy & 90% respond to turbinectomy Aleem, et al, 2010: Pakistani Armed Forces Journal 4: November 2. Septoplasty + partial turbinectomy is more likely to lead to long term relief of nasal obstruction in pts with septal deviation and turbinate hyertrophy than septoplasty alone Marais J, et al, 1994: Rhinology 32(3):145-7. 3. Chronic „4 finger sinus headache‟ which is refractory to medical therapy responds to partial middle turbinectomy Clerico, et al. 1997: Rhinology 35:98 4. 10% rhinoplasty pts following lateral osteotomy develop nasal obstruction without reduction of the inferior turbinate Beekhuis GJ, 1976: Laryngoscope 86(4):540-8 4 Reasons Why I Perform Turbinectomy
  • 4. Paradoxical sensation of nasal obstruction, following partial or total inferior & or middle turbinate resection • +/- lack of sensation to air flow • +/- stuffiness and too much air flow • +/- nasal dryness • +/- feeling of being „crippled‟ and depression Definition of Empty Nose Syndrome ( ENS ) Kern, 1997: Am Rhinologic Soceity Spring Meeting
  • 5. Ozena: Triad of fetor, crusting and atrophy of nasal structures ( Dr Bernard Frankel, 1876 ) • Anosmia • Foul Odor • Crusting • Congestion sensation • Enlargement of nasal cavity with loss of turbinates • Squamous metaplasia Not Ozena: obliterating endarteritis ( Ruskin, 1932* ) * Arch Otolaryngol 15(2):222-257 Definition of Atrophic Rhinitis ( aka: Rhinitis Sicca ) .. ..
  • 6. • Partial turbinectomy ( 56%) • Total turbinectomy ( 24%) • Sinus surgery (10%) • Radiation therapy (2.5%) • Nasal trauma (1%) • Granulomatous diseases (1%) Sarcoid Infections: Leprosy Klebsiella Rhinoscleroma Tuberculosis Causes of Atrophic Rhinitis Moore & Kern. Amer J Rhin. 2001, 15(6): 355-361
  • 7. • Spielberg W, 1924: overzealous resection might cause Laryngoscope 34:197-203 • Rustin SL, 1932: might cause atrophic rhinitis Arch Otolaryngol 15(2): 222-257 • Goode R,1978: may occur with alpha blockers J Otolarygngol 7(3):262-8 • Clayman LZ, 1979: in the „black‟ nose: too much air flow Plastic &Recon Surg63(5):718-9 may worsen anterior rhinorrhea Atrophic Rhinitis Following Turbinectomy
  • 8. •Moore GF, et al, 1985: 18 east coast pts: total bilateral inferior turbinectomy Laryngoscope 95:1095-1099 72% (13) + septoplasty follow-up (f/u) 3-5 years, same patients < 3 years f/u no complications reported 89%(16) reported new onset dryness and crusting 34% (6) new onset malodor detected •Elwany S & Harrison 1990: J Laryngol & Otol 104:206-209 20 egyptian patients „partial‟ inferior turbinectomy < / = 1 yr follow-up, variable amount resected Is Inferior Turbinectomy Harmful ?: Yes
  • 9. •Oburra HO, 1995: 34 kenyan patients total bilateral inferior turbinectomy East African Me d J72(2):101-2 22% complication rate with unspecified follow-up 15%(5) developed atrophic rhinitis •Berenholz L, et al, 1998: 42 pts israeli underwent total turbinectomy Am J Rhinol12(4):257-61 ? % bilateral, ? duration of follow-up 31%(13) developed new onset symptomatic chronic sinusitis •Passali, et al, 2003: 45 italian patients underwent inferior turbinectomy AnnOtol Rhinol Laryngol yearly follow-up for 6 years: unchanged symptom scores Is Inferior Turbinectomy Harmful?: Yes
  • 10. •Courtiss E H et al, 1978: 88 pts, 110 total inferior turbinectomy Plast & Recon Surg 62(20249-57 3.4% complication: bleeding, 1/3 required transfusion No other reported complications “ Unable to find a documented atrophic rhinitis ” •Martinez SA et al, 1983: 29 pts total inferior turbinectomy Laryngoscope 93:871-5 27 bilateral , 75% with septoplasty follow-up 2-60 months 2 with mild dryness and crusting, no ENS •Carrie S, et al, 1995: 14 patients with bilateral total inferior turbinectomy Clin Otolaryngol 21:139-41 > 7 yr follow-up & acoustic rhinometry No symptoms / signs of atrophic rhinitis / Does Inferior Turbinectomy Cause Atrophic Rhinitis ?: No
  • 11. •Pollack and Rohrich, 1984: 183 pts 1/3-1/2 partial inferior turbinectomy Plast &Recon Surg 74(2):227-236 90% long term relief nasal obstruction 80% >12 months follow-up (25% >3 yrs) No patients developed atrophic rhinitis •Ophir, et al, 1985: 150 israeli pts total & bilateral inferior turbinectomy Arch Otolarygol 111:93-5 85% success in relieving nasal obstruction 4.6% (7) complication: bleeding, 2 required transfusion No symptoms / signs of atrophic rhinitis / ENS •Mabry, 1988: 40 patients anterior 1/2 inferior turbinectomy Does Inferior Turbinectomy Cause Atrophic Rhinitis?: No
  • 12. Houser, 2006: Arch Otolaryngol Head Neck Surg 133(9):858-63 • Single case report endoscopic subtotal middle turbinectomy & endoscopic ethmoidectomy followed by revision 3 yrs later & sphenopalatine ganglion ablation • Complications: left nasal stuffiness, nasal cold air intolerance and pain • Underwent alloderm submucosal septal implantation and Cymetra injectable into the septal implanted area with > 40% improvement Does Middle Turbinectomy Cause ENS?: Yes
  • 13. • Morgenstein & Kreiger, 1980: 36 pts underwent middle turbinectomy Laryngoscope 90:1596-603 19 for headache and 13 bilateral 2.7%(1) complication: bleeding & synechia No patients developed atrophic rhinitis • Lawson, W., 1991: 1077 partial (1/2) middle turbinectomy & total ethmoidectomy Laryngoscope 101(4Pt1):367-71 follow-up at least 2 years 2 cases of hemorrhage None developed atrophic rhinitis • Giacchi, etal, 2000: 100 pts retrospective non randomised case study J Rhinology 14:93-97 1/ 2 partial middle turbinectomy & endoscopic ethmoidectomy middle turbinectomy reduced recurrent sinusitis Does Middle Turbinectomy Cause Atrophic Rhinitis?: No
  • 14. Grutzenmacher, et al, 2003: ORL 65:341-347 6 „normal noses‟ filled with silicone and acrylic molds were then made: 4 Groups Each measured by acoustic & manometric rhinometry Normal nose Even flow distribution Hyperplastic Reduced rhinometry+flow acrylic polymer & even flow distribution (simulated) „Turbinectomy‟ Turbulence increased & & normal nose reduced air flow resistance (simulated) Is Combined Turbinectomy Harmful: No/Yes inferior middle
  • 15. • Fry HJ, 1973: 200 pts „judicious‟ partial inferior and middle turbinectomy Aust NZJ Surg 42(3):291-4 +/- reduction rhinoplasty +/- septoplasty +/- ethmoidectomy middle turbinectomy reduced recurrent sinusitis no cases of atrophic rhinitis / ENS Does Combined Turbinectomy Cause ENS?: No
  • 16. • 2004 - 2011: retrospective case series, n= 87 patients • Follow-up: data collected from May 2010 - January 2012 • All patients underwent detailed telephone interview chart review & office examination • Post-surgery symptoms analysis was determined using a Subjective Units of Improvement Scale ( SUIS ): 0 - no improvement 10 - resolution • The duration of post operative benefit was recorded • A list of the most common post - operative symptoms was Is turbinectomy safe to perform in my patients ? Methods
  • 17. • Indications for surgery > nasal obstruction: > 6 months ( often many years ) > middle turbinate headache: > 6 months (often many years ) > refractory to medical therapy: > 6 weeks continuous therapy > high risk for nasal obstruction following rhinoplasty: infracture osteotomy • Surgical Technique > nasal obstruction: anterior 1/3, 1/2 or subtotal inferior turbinectomy > chronic sinus headache: inferior 1/2 middle turbinectomy > +/- combined with: uvelopalatoplasty, submucous resection of the nasal septum, nasal valve reconstruction, tonsillectomy endoscopic sinus surgery rhinoplasty with in fracture osetotomy • same surgeon • all cases packed with Mericel sponge packing for 4 days Methods
  • 18. • 87 Patients • Sex: 40 Female 47 Male • Age: 16 years to 95 years: mean 55.5 years • Follow-up: 2 months to 6 years: mean 42.4 months • 172 turbinectomies performed Results
  • 19. Symptom(s) Subjective Units of Improvement Scale: 0-10 Symptom resolution marked mild none n=Specific Procedure 10 >=7 <=6.9 0 Nasal Obstruction 5 4 2 3 14 S+BIT (n = 50) 5 4 0 0 9 To+S+BIT 2 5 0 0 7 To+BIT 3 2 1 0 6 ESS+BIT+BMT 1 2 2 0 5 UVP+S+BIT 1 1 0 1 3 UVP+R+BIT 0 3 0 0 3 IT (1/3 Unilateral ) 0 2 0 0 2 NVR+BIT+BMT 0 80% 0 1 20% 0 1 UVP+NVR+S+BIT ___________________________________________________________________________________________ _________ Nasal Obstruction & 1 6 0 1 8 UVP+BIT/MT/NVR Headache 1 4 1 0 6 ESS+BIT+BMT 1 3 1 0 5 R+BIT+BMT/S (n = 37)
  • 20. 14 Persistent Symptoms in 13 Patients Nasal Obstruction (13) 13/87 ( 14.9 %) 4: S+BIT 6 unilateral 2: ESS+BIT/MIT 7 bilateral 1: R+BIT+MIT 1: R+MIT 1: S+BIT+MIT 1: NVR+S+BIT 1: To+BIT Headache (1) 1/37 ( 2.7%) 1: NVR+S+BIT * * no MT surgery performed Results
  • 21. Causes of Persistent Nasal Obstruction Pts ( n= 13 /87: 15%) • Nasal valve collapse (NVC) 12 • ENS 1 ? Causes of Persistent Headache Pts ( n=1) • Untreated middle turbinate impaction on septum 1 Results
  • 22. Complications of surgery ( 12/87 ) Number Patients Procedure(s) Increased rhinorrhea 5 ( 5.7%) 2:S+ESS+1/2BIT 1: ESS+1/2BIT 1:NVR+BIT+BMT 1:To+S+BIT+NVR Bleeding requiring repacking 4 ( 4.6%) 3:1/2BIT,1:BIT Mild long term crusting * 2 ( 2.3%) 1:S+BIT, 1:NVR+BIT *both associated with NVC New onset nasal obstruction 1 ( 1.1%) 1:R+BIT * will discuss Results
  • 23. Atrophic Rhinitis / ENS from Surgery Pts Atrophic Rhinitis 0 ENS 1 ? * * History: 54yr asian female minimal complaint of nasal congestion s/p forehead flap reconstruction of tip defect from carcinoma external valve narrowed L>R, retracted columella, depressed tip tight circumferential scarring of the nasal tip angry at all 3 previous surgeons unemployed for 3 years Surgery: septal cartilage grafts, scar excision, local flaps & right 1/3 inferior turbinectomy, left 1/2 inferior Results
  • 24. 1. Persistent Nasal Obstruction following Turbinectomy is usually caused by nasal valve collapse and not ENS 2. The extent of surgery should match the extent of the problem Less <----- ie. how much to remove ? -----> More Failed C pap & nasal obstruction severe allergic rhinitis / polyposis / septal deviation 3. Differences in anatomy: narrow versus broad external nasal valve ? Leptorrhine not = platyrrhine nose 4. Psychological profile: Gorney‟s „Simon vrs. Sylvia‟ ? Single, immature, male, obsessive, narcissistic vrs. Secure, young, listens, verbal, intelligent, attractive 5. Can turbinectomy cause intra-nasal RSD: Reflex Sympathetic Dystrophy ? 5 Sources of Controversy ?
  • 25. Summary • Turbinectomy: safe procedure in the crowded nasal airway • Inferior Turbinectomy was associated with > 85% relief of nasal obstruction • Persistent nasal obstruction following inferior turbinectomy was due to nasal valve collapse in 12 / 13 patients. • Partial middle turbinectomy was > 97% successful in relieving headaches • Turbinectomy should be avoided when there is an enlarged airway or if there is xero-rhinitis from whatever cause • Exhibit caution in performing turbinectomy in patients with a: a. platyrrhine nose: african - american & asian nose b. abnormal psychological profile
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