Outcomes of Powered-Assisted Endoscopic Inferior Turbinoplasty

1. Medical Report Of :
Outcomes of Powered-Assisted
Endoscopic Inferior Turbinoplasty
By:
Dr. Shalan Mufleh Darak Haded
M.B.Ch.B
Al-Shaheed Gazi Al-Hariri hospital
for surgical specialities in the medical city
Baghdad 2014

2. Abstract
Aim of study: evaluation the outcomes of powered-assisted endoscopic
inferior turbinoplasty in relieving the nasal obstruction.
Methods:study included 25 patients complaining from persistent nasal
obstruction of more than 6 months despite of medical treatment for about
3 months. A powered-assisted endoscopic inferior turbinoplasty was done
for each patient and the patients were followed for the 1st week, 1st month
and 3rd month post-operatively.
Results:Preoperatively, nasal obstruction was 12% moderate and 88%
severe while postoperative 3rd month 80% had no nasal obstruction and
20% had still mild obstruction. In other hand, the endoscopic grading of
inferior turbinate was 76% grade III and 24% grade II in preoperative
evaluation, then it became 88% grade I and 12% grade II in postoperative
3rd month. Therefore, there is significant changes in both nasal
obstruction and turbinate size(p value=<0.05).
24% of patients developed mucosal tear during surgery without mucosal
loss, 8% developed mild bleeding during removal of the packs and it
needed only digital pressure to stop, 8% of patients developed crust
formation during the 1st month postoperatively, then after instructing the
patients to use nasal saline wash along with antibiotics for 2weeks, the
crust disappeared.
Conclusion:outcomes of powered-assisted endoscopic inferior
turbinoplasty were significant regarding relieving the nasal obstruction
with few postoperative complications.

3. Introduction:
The inferior turbinates serve several important functions,including
warming, humidifying and cleaning the inspired air.However, they are
also the mainstructures contributing to chronic nasal obstruction.Several
surgical techniques have been used to reducethe turbinate(33), however, no
technique is perfect and each is associated with known short- andlong-
term complications such as post-operative bleeding,crusting, foul odour,
pain, hyposmia andsynechiae.
With the introduction of microdebriders to rhinosurgery by Setcliff and
Parsons, many surgeons began toperform submucosal resection during
inferior turbinoplasty,utilizing the advantages of the powered system.(37)
This technique has been reported to be safe method of achieving turbinate
size reduction with minimal morbidity.
Patients and Methods:
This prospective study conducted in Al-Shaheed Gazi Al-Hariri hospital
for surgical specialities in the medical city/ Baghdad from October 2012
to October 2013. The study included 25 patients complaining from
persistent nasal obstruction of more than 6 months despite of medical
treatment which consists of: intranasal steroid (budesonide nasal spray 64
microg 2puffs bid for 3months), antihistamine (loratidine tab.10mg once
at night for 3months) and intranasal decongestant(oxymetazoline nasal
drops for first 5days) .
Inclusion criteria:
1. Persistent nasal obstruction due to inferior turbinate mucosal
hypertrophy , unilateral or bilateral , with or without septal
deviation.
2. Failure of medical treatment for 3 months.
3. Age >18 years old.

4. Exclusion criteria:
1. Inferior turbinate bony hypertrophy.
2. Patients with nasal polyposis, tumors and granulomatous diseases.
All patients were evaluated by full clinical assessment, starting from
taking full history about the nasal obstruction (onset, duration, severity,
site) with associated nasal symptoms, along with past medical and past
surgical history.
Each patient used a 4-points visual analogue scale (VAS) to grade his
nasal obstruction separately preoperatively (day 0), at 1st week, 1st
month and 3rd month after surgery. For example, score of 0 represented
no nasal obstruction, a score of 1 represented mild obstruction(causing no
disturbance in patient's daily life), a score of 2 represented moderate
obstruction(forcing the patient to breath through his mouth), while a score
of 3 represented severe obstruction(causing sleep disturbances and
decrease in voice quality) .
After that complete nasal examination was done including nasal patency
test (cold spatula test ), Cottle's maneuver, anterior rhinoscopy and nasal
rigid endoscopy before and after nasal decongestant to exclude bony
inferior turbinate hypertrophy.
Next, we evaluate each patient's nasal patency while we perform a
modified Cottle maneuver that involves two different nasal manipulations
: elevation of lower lateral cartilage and upper lateral cartilage using ear
probe and evaluate the patency on VAS, then applying nasal decongestant
drops(oxymetazoline 1%) and repeat all examination and evaluation
again. Only these patients that had relief of their nasal obstruction after
applying decongestant were included and will get benefit from
turbinoplasty.
We graded the inferior turbinate from I to III, as Grade (I) was defined as
mild enlargement with no obvious obstruction, Grade (III) was complete
occlusion of the nasal cavity. The turbinates in between were graded as
Grade (II).
In patients with nasal septal deviation, we evaluate the side with
compensatory turbinate hypertrophy with the same method and
interestingly we noticed that most of our patients considered that side as
the main side of obstruction compared to that with septal deviation.

5. All patients sent for routine preoperative investigations (CBP, ESR,
bleeding profiles, viral screening) along with Computed tomography of
nose and paranasal sinuses in axial and coronal views for assessment and
planning surgery.
We divided the patients into two groups: group A consisted of 10 patients
who had bilateral inferior turbinate hypertrophy and received endoscopic
inferior turbinoplasty, and group B consisted of 15 patients who had
septal deviation with contralateral inferior turbinate compensatory
hypertrophy and received endoscopic inferior turbinoplasty along with
septoplasty.
All patients were informed about the details ofthe procedure to achieve
the ethical point of view and written consents were taken from all the
patients.
Operative procedure:
Under general anesthesia using endotracheal intubation, with the patient
lying in supine position with head elevated 15°, using Hopkins rod 0°
endoscope, and applying local nasal packs soaked with Oxymetazoline
1% inserted in the nasal floor medial and anterior to head of inferior
turbinate for 10 minutes. Then we precede the procedures in these steps:
1. Using endoscope, we did incision about half cm in the anterior
head of the inferior turbinate using No.15 blade in vertical manner.
2. We made a submucosal pocket along the medial side of inferior
turbinate through that incision using Freer's elevator.
3. A straight microdebrider blade (2.0 mm) incorporated with an
elevator (Medtronic XomedInc, Jacksonville, Fla) was inserted
through the incision into the pocket. Debridement of submucosal
tissue from the inferior turbinate was performed, moving back and
forth in a sweeping fashion with the blade positioned
mediolaterally from the submucosal plane at a speed of up to 3000
rpm. Particular attention was paid to preserve the mucosal flap.
Immediate shrinkage of the size of turbinate was observed. This
done bilaterally for patients in group A, while only in the side of
compensatory hypertrophy in patients in group B.

6. 4. The incision was not closed, and merocel nasal packs were
inserted. The procedure took about 10 to 15 minutes each side.
5. in group B, we did conventional septoplasty to them with insertion
of bilateral silastic sheets.
Post-operative follow-up:
1. Merocel packs were removed 48 hours post-operatively.
2. Patients were instructed to take antibiotics(amoxiclave 625mg 1*3
for 7 days) along with nasal saline wash and nasal
decongestant(oxymetazoline drops 1% for 5days)and intranasal
steroid(budesonide nasal spray 64 microgm 2puffs bid for one
month).
3. Silastic sheets were removed after one week post-operatively.
4. Patients were seen one week, one month and 3 months post-
operatively and all the evaluation methods ( VAS, endoscopic
nasal examination) were done.
5. Complications of bleeding, mucosal tears, crusting or synechia
were treated.
Results:
Age distribution:
The range of patient age is between 18 to 43 years with average is 25
years.
Table(1) age distribution
Age group(year) No. of patients Percent
18-28 19 76
29-38 5 20
39-48 1 4

7. gender distribution:
in this study, we have 10 male patients and 15 female patients.
Table(2) gender distribution
Sex No. of patients Percent
Male 10 40
Female 15 60
Total 25 100
Sideof turbinatehypertrophy :
During pre-operative assessment, we have 15 patients (60%) that had
unilateral turbinate hypertrophy while 10 patients (40%) that had bilateral
turbinate hypertrophy.
Table(3) side of turbinate hypertrophy
Side of turbinate
hypertrophy
No. of patients Percent
Unilateral 15 60
Bilateral 10 40
Total 25 100
Type of surgery:
We have 2groups according to the type of surgery, group A had bilateral
turbinoplasty for 10 patients, and group B had unilateral turbinoplasty
along with septoplasty for 15 patients.
Table(4) type of surgery
Type of surgery No. of patients Percent
Bilateral
turbinoplasty
10 40
Unilateral
turbinoplast with
septoplasty
15 60
Total 25 100

8. Subjectiveevaluationof nasal obstruction:
Subjective symptom of nasal obstruction was evaluated on pre-operative
day, and 1st week,1st month and 3rd month post-operatively using 4-point
scale.
Table(5) subjective evaluation of nasal obstruction
Pre-
operative
day
1st
week
post-
operatively
1st
month
post-
operatively
3rd
month
post-
operatively
0 no nasal
obstruction
0 3(12%) 18(72%) 20(80%)
1 mild
obstruction
0 15(60%) 7(28%) 5(20%)
2 moderate
obstruction
3(12%) 7(28%) 0 0
3 severe
obstruction
22(88%) 0 0 0
Endoscopicgradingof inferior turbinate:
Accordingto Friedman et al(39), we graded the inferior turbinate into 3
grades : Grade (I) was defined as mild enlargement with no obvious
obstruction, Grade (III) was complete occlusion of the nasal cavity. The
turbinate in between was graded as gradeII. We did this grading using
endoscopic examination in pre-op. day 0 , post-op. 1st week, 1st month
and 3rd week.
Table(6) endoscopic grading of inferior turbinate
Grade Preop. 1st
week
postop.
1st
month
postop.
3rd
month
postop.
Grade I 0 21 22 22
Grade II 6 4 3 3
Grade III 19 0 0 0
PearsonChi-Square=53.977; DF=6 ; P-Value= 0.0001 SN

9. Complications:
1-Mucosal tear:
Per-operatively, we observed that 6 of patients (24%) develop mucosal
tear but without mucosal flap loss.
Table(7) mucosal tear
Mucosaltear No. of patient Percent
Presence 6 24%
Absence 19 76%
2-Bleeding:
Per-operatively, no one of our patients develops major bleeding that need
further intervention, while post-operatively ( at time of pack removal/48
hours) there is mild bleeding reported in 2patients(8%), required only
digital pressure to stop.
Table(8) bleeding post-operatively
Bleeding No. of patients Percent
Presence 2 8%
Absence 23 92%
3-Crust formation:
At the 1st month post-operatively, we observed crust formation in 2
patients (8%). We instruct them to use aggressive nasal saline wash along
with antibiotics for 2weeks, the crust disappeared.
Table(9) crust formation
Crust formation 1st
month
Presence 2(8%)
Absence 23(92%)

10. Discussion:
In this study, a total 25 patients were conducted in prospective study to
evaluate the outcomes and complications of powered assisted endoscopic
inferior turbinoplasty. The age of the patients were between 18 and 43
years while in study by Friedman.et al(26) the age was between 19 and 71
years, and study by Hegazy H. et al(42) the age was between 19 and 35
years. Our group age groups were cooperative and more precise in
evaluating the sense of nasal obstruction.
The gender distribution in our study was 10 males(40%) and 15
female(60%) while in study of Friedman et al , the gender distribution
was 78 males and 42 females. In study of Hegazy H. et al, the gender
distribution was 22 males and 28 females.
As subjective evaluation in our study before surgery, there were 3(12%)
patients that had moderate nasal obstruction, while 22(88%) patients had
severe nasal obstruction. After surgery(3rd month post-operatively), a
20(80%) patients had no nasal obstruction, while 5(20%) patients still had
mild nasal obstruction. In study of Friedman et al, a 83% of the patients
were suffered from severe nasal obstruction, while 17% had moderate
nasal obstruction before surgery. After surgery, 25%of the patients had
mild nasal obstruction and 75%hadno nasal obstruction. In his study,
Hegazy H. et al showed that 90% suffered from severe nasal obstruction
and 10% had moderate nasal obstruction pre-operatively. But after
surgery, 20% had mild nasal obstruction while 80% had no nasal
obstruction.
As objective data in our study, we have 6(24%) patients had grade II
inferior turbinate hypertrophy, while 19(76%) patients had grade III
before surgery. In the 3rd month after surgery, 22(88%) patients had grade
I while 3(12%) patients had grade II inferior turbinate (P value<0.05). In
his study, Friedman et al had 74(32%) grade II and 158(68%) grade III
inferior turbinate before surgery. After surgery, they observed 166(72%)
grade I and 66(28%) grade II inferior turbinate. In comparison, Hegazy
H. et al had 10(11%) grade II and 80(89%) grade III inferior turbinate
before surgery. After surgery, they observed 85(94%) grade I and 5(6%)
grade II. So, we found that our results are similar to these studies because
we apply the same methods and procedures used in these studies. In our
study, we depend on 3months follow up while in the study of Friedman
et al, they used 6months follow up, and Hegazy H.et al used 8weeks

11. follow up. We chose this period because the healing process nearly
completed and all the complications appeared at this time.
During our procedure, we had 6(24%) patients that developed mucosal
tear in the mucosal flap without mucosal loss, while in Friedman et al
study there were fairly common in 55% of the patients. In contrast, in the
study of Hegazy H.et al the mucosal tears were in 42(47%) turbinates
mainly in cases with thin mucosa. In other study to Huang and
Cheng(43), 5 patients (10%) had mucosal tears. Compared with studies of
Friedman and Hegazy that used microdebrider blades (3.5 or 4.0mm). In
our study, we used newly designed much smaller blade (2.0mm)
incorporated with an elevator for protection of mucosal flap, causing less
complications such as mucosal tears, bleeding and synechia.
Regarding bleeding, no one of our patients (0%) develops major bleeding
per-operatively, while post-operatively ( at time of pack removal/48
hours) there is mild bleeding reported in 2 patients(8%), required only
digital pressure to stop. In his study, Friedman et al reported two
patients (1.6%) that develop postoperative bleeding that required a return
to the operating room. In contrast, Huang and Cheng reported no
patients had any postoperative bleeding after removal of the nasal
packing after 24 hours. Our results were due to use of 2.0mm
microdebrider blade and Merocel nasal packs which cause less mucosal
injuries and bleeding at time of packs removal.
In our postoperative evaluation( 1st month), we observed 2patients(8%)
that had crust formation, then after instructing the patients to use nasal
saline wash along with antibiotics for 2weeks, the crust disappeared.In
comparison, Friedman et al did not observe any crust formation, while
Hegazy H.et al reported mild crusting and dryness in 5 of 50
patients(10%). Our results were probably due to mucosal tearing that
happened during procedure and due to dry climate of our country.

12. Conclusion:
The result of this study revealed that the outcomes of powered-assisted
endoscopic inferior turbinoplasty were significant in relieving the nasal
obstruction, and it is a safe method in reduction of turbinate size with few
postoperative complications.
Recommendations:
1. Increase number of patients with longer follow-up period in
future studies.
2. Compare this technique with other techniques used in reduction
the size of inferior turbinate.
3. We recommend to use powered-assisted endoscopic inferior
turbinoplasty for reduction of turbinate size.

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