1) Sandwich therapy involves using a combination of treatments where one type of therapy is administered before and after another treatment. It is commonly used to treat inferior turbinate hypertrophy. 2) Medical therapy is usually the first treatment tried and includes oral or intranasal antihistamines, topical corticosteroids, or combinations. Surgery is considered when medical therapy fails or obstruction persists. 3) Surgical treatments for turbinate hypertrophy aim to reduce the size of the turbinates but should avoid radical or total resection to prevent complications. Radiofrequency ablation and use of a debrider are alternative surgical options.

1. La terapia Sandwich:
come e quando
Vittorio Ferrero
SC Otorinolaringoiatria
Ospedale Mauriziano

2. Definizione
Sandwich therapy (sand-wich) n. a combination of
treatments in which one type of therapy (e.g. a surgical
operation) is ‘sandwiched’ between exposures to another
treatment (e.g. pre- and postoperative medical
treatment).

3. Cause ipertrofia turbinati
• Rinite allergica
• Rinite non allergica

4. Riniti non allergiche (NAR)
• NARES: NAR con eosinofili
• NARNE: NAR con neutrofili
• NARMA: NAR con mastociti
• NARESMA: NAR con eosinofili
e mastociti
Courtesy: by Gelardi

5. Costi malattie allergiche
• Rinite allergica, asma, ipertrofia dei turbinati e
congiuntivite allergica
• Costi totali: 7,33 Miliardi di Euro
• 27.5% Costi indiretti
• 72.5% Costi diretti
• Ipertrofia dei turbinati: 12 Milioni di Euro
500 milioni di persone/worldwide
• Forte impatto qualità della vita
Recenti Prog Med. 2015 Oct;106(10):517-27. doi: 10.1701/2032.22086.
Direct and indirect costs associated with respiratory allergic diseases in Italy. A probabilistic cost of
illness study Marcellusi A, Viti R, Incorvaia C, Mennini FS.

6. Funzionalità nasale
• Funzionalità nasale dipendente da aria
respirata (umidità, temperatura,…)
• Resistenze vie aeree: 50% cavità nasali
• Di queste 40% dovute agli scambi a livello dei turbinati
• Se ipertrofia: 80%
Fonseca MT, Voegels RL, Pinto KM. Evaluation of nasal volume by acoustic
rhinometry before and after physical exercise. Am J Rhinol 2006;20: 269–273.

7. Terapia medica
• Primo trattamento
• Antistaminici orali o intranasali
• Cortisonici topici
• Associazione
• Secrezione abbondante
•Anticolinergici (es. Ipratropio bromuro)

8. • Antistaminico orale+steroide topico o steroide
topico solo?
• SAR Steroide topico+Antistaminico o steroide topico
solo
• PAR Steroide topico
• Terapia topica: Antistaminico+steroide o
steroide solo?
• SAR e PAR Steroide+Antistaminico topico o steroide
topico solo, non Antistaminico topico solo
• Terapia sistemica: Leucotrienico o
• antistaminico?
• SAR Leucotriene o Antistaminico
• PAR Antistaminico

9. Quando chirurgia?
• Quando la terapia medica fallisce
• Se permane ostruzione respiratoria

10. Terapia chirurgica
• E’ la scelta vincente?
• In the absence of evidence that inferior turbinate surgery is
an effective tool for allergic rhinitis, these interventions are
not recommended for routine use until such corroborative
research becomes available.

11. Terapia chirurgica
• Mai trattamenti radicali
• Moore (1985): “total inferior turbinectomy should be
condemned”
• Riduce la superficie mucosa in grado di
scambiare calore e umidità
• Rischio rinite atrofica e “empty nose”
• The stimulation of cold receptors may diminish after
aggressive turbinate resection, potentially
contributing to the paradoxical sensation of nasal
obstruction reported by empty nose syndrome patients
Moore GF, Freeman TJ, Ogren FP, Yonkers AJ. Extendedfollow up of total
inferior turbinate resection for relief of chronic nasal obstruction.
Laryngoscope 1985;95:1095–9.
Impact of Middle vs. Inferior Total Turbinectomy on
Nasal Aerodynamics Anupriya Dayal, BS, John S. Rhee, MD, MP,
and Guilherme J. M. Garcia, PhD Otolaryngol Head Neck Surg. 2016 September
; 155(3): 518–525

12. Simmen, Jones: Manual of endoscopic Sinus Surgery, Thieme

13. Terapia chirurgica
Impact of Middle vs. Inferior Total Turbinectomy on
Nasal Aerodynamics Anupriya Dayal, BS, John S. Rhee, MD, MP,
and Guilherme J. M. Garcia, PhD Otolaryngol Head Neck Surg. 2016 September
; 155(3): 518–525

14. Terapia chirurgica
Impact of Middle vs. Inferior Total Turbinectomy on
Nasal Aerodynamics Anupriya Dayal, BS, John S. Rhee, MD, MP,
and Guilherme J. M. Garcia, PhD Otolaryngol Head Neck Surg. 2016 September
; 155(3): 518–525

15. Terapia chirurgica
Impact of Middle vs. Inferior Total Turbinectomy on
Nasal Aerodynamics Anupriya Dayal, BS, John S. Rhee, MD, MP,
and Guilherme J. M. Garcia, PhD Otolaryngol Head Neck Surg. 2016 September
; 155(3): 518–525

16. Terapia chirurgica
Radiofrequenze

17. Terapia chirurgica
Debrider

18. Quando sandwich?
THE ROLE OF NASAL CYTOLOGY IN THE MANAGEMENT OF INFERIOR TURBINATE HYPERTROPHY
M. CASSANO , A. MASELLI DEL GIUDICE" G. RUSSO., L. RUSSO and G. CIPRANDI
INTERNATIONAL JOURNAL OF IMMUNOPATHOLOGY AND PHARMACOLOGY Vol. 26, no. 1,207-215 (2013)

19. Quando sandwich?
• In caso di rinosinusite cronica
• La riduzione dell’ipertrofia dei turbinati
inferiori migliora significativamente la
distribuzione del farmaco topico a livello del
meato medio
The effect of inferior turbinate hypertrophy on nasal
spray distribution to the middle meatus
A.C. DOWLEY& J.J. HOMER
Clin. Otolaryngol. 2001, 26, 488–490