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N
asal obstruction, for the Rhinology clinic, is a frequently presented symptom and has been
shown to adversely affect patients’ quality of life.1 It is a troublesome problem for the surgeon
as well as the patient. There are a number of possible anatomical causes for this symptom:
frequent. Here we aim to present a summary of endoscopic inferior turbinectmy by discussing both the
anatomy and physiology, and also the pathophysiology of this technique. We then move onto the
Mr KW S Ah-See
pre-op assessment, technique and post-op treatment.
Consultant
Otolaryngologist-Head
and Neck Surgeon,
Aberdeen Royal Infirmary,
Foresterhill,
Aberdeen,
AB25 2ZN, UK.
Tel: +44 (0)122 455 3571,
Email: [email protected]
Contributors to
‘How I Do It’
Mr B Ram,
Consultant ENT Surgeon,
Aberdeen Royal Infirmary, UK.
Mr J Newton, ENT SpR,
East of Scotland ENT rotation,
currently based at Aberdeen
Royal Infirmary, UK.
Mr M Shakeel, ENT career SHO,
Aberdeen Royal Infirmary, UK.
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enlarged inferior turbinates, deviated nasal septum, and a narrow internal nasal valve area are the most
Mr KW Ah-See, MD,
FRCS, FRCS(ORL),
Declaration of
Competing Interests
None declared.
09:46
Endoscopic Inferior Turbinectomy
‘How I Do It’ is compiled by
Correspondence
Mr B Ram,
Aberdeen Royal
Infirmary, Aberdeen,
AB25 2ZN, UK.
23/8/07
Inferior turbinate enlargement can be secondary to
mucosal hypertrophy or bony hypertrophy – or
both. If the bone is involved then it causes a permanent obstruction while there will be fluctuation in
nasal obstruction in mucosal hypertrophy.
Conservative treatment in the form of steroids, antihistamines and decongestants are usually successful,
however some patients are refractory to medical
therapy.
Reduction of the inferior turbinates has been performed for more than 100 years. The aim of surgery
is to correct the anatomical abnormality and consequently improve nasal obstruction and restore normal breathing and drainage. In addition, this also
potentiates the medical management of rhinitis, by
improvement of delivery of the topical medications
to the superior nasal cavity.2 Effective turbinate
reduction surgery can be a challenge and many techniques have been developed to achieve this. Partial
turbinectomy, radical turbinectomy, laser therapy,
electrocautery, cryotherapy, submucosal resection,
and submucosal resection with lateral displacement3
all have their advocates.
Anatomy and Physiology
Inside the nasal cavity, there are three bony projections from the lateral nasal wall called turbinates or
conchae (the superior, middle and inferior
turbinates). The superior and middle turbinates are
part of the ethmoid bone. The inferior turbinate is a
separate bone,4 which does not extend all the way
into the fleshy posterior tip.5 The inferior turbinate is
60mm long, 7.5mm high and 4mm wide. The arterial supply to the inferior turbinate mainly comes
from the descending branch of the sphenopalatine
artery, which enters the superior aspect of the inferior turbinate up to 15mm from the posterior tip. This
artery then divides into a smaller posterior branch,
which lies entirely within the soft tissue supplying
the posterior tip, and two larger anterior branches,
which supply to the rest of the turbinate. The sensory nerve supply of the turbinates comes from the
anterior palatine nerve and the lateral nasal nerve.
The sympathetic fibres originate from the first and
second thoracic segments of the spinal cord. The
parasympathetic preganglionic fibres arise from the
superior salivatory nucleus. The turbinates are lined
by pseudostratified ciliated columnar epithelium
containing numerous goblet cells. The mucous
membrane covering the middle and inferior
turbinates contain additional venous sinusoids
located between the capillaries and venules.
Pathophysiology
The internal nasal valve area is bounded by septum
medially and laterally by the caudal edge of the upper
lateral cartilage. The anterior end of the inferior
turbinate lies in the internal nasal valve area and any
degree of hypertrophy affecting it greatly increases
the airflow resistance and consequently causes nasal
obstruction. Studies have shown that mucosal
swelling is not solely responsible for nasal obstruction
in enlargements of the inferior turbinate.6 Bony
hypertrophy plays a large role and this supports trimming as the treatment of choice.
Pre-op assessment
A detailed history is taken and a thorough ENT
examination is performed: anterior rhinoscopy as
well as rigid nasendoscopy is mandatory.
A computed tomography (CT) scan can be done
in selected cases to find out the state of paranasal
sinuses.
Technique
Local anaesthetics may be suitable for minor procedures to the turbinates, but trimming of the
turbinates requires a full general anaesthetic. The
anaesthetist should pay particular attention to protection of the airway from blood, using either an
oro-tracheal tube with pharyngeal packing or a
laryngeal mask.
The patient is prepared for a standard endonasal
procedure using the following preparations. On the
ward 30 minutes pre-operatively the patient’s nose is
packed loosely with ribbon guaze (impregnated with
lidocaine hydrochloride 5% with phenylephrine
hydrochloride 0.5%). After induction of anaesthesia,
xylometazoline 0.1% (otrivine) is poured into both
nares. Finally the inferior turbinates are infiltrated
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2
1
5
3
Bony hypertrophy plays a large
role and this supports trimming
as the treatment of choice
4
6
8
Figure 1: Pre-operative appearance
of left inferior turbinate.
Figure 2: Injecting Lignospan into
anterior end of inferior turbinate.
Figure 3: In-fracture of inferior turbinate.
Figure 4: Trimming of turbinate.
Figure 5: Removal of excised turbinate.
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Figure 6: Securing haemostasis after trimming.
Figure 7: Securing haemostasis after trimming.
Figure 8: Post-operative appearance:
posterior stump demonstrated.
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Bent anterior end of suction diathermy.
with 1:80,000 adrenaline with 2% lidocaine hydrochloride
(Lignospan Special) to the anterior and middle thirds.
An initial assessment of the nasal anatomy is carried out using the
0° 4mm nasal endoscope. Once the diagnosis has been confirmed
and other nasal pathology excluded, the inferior turbinate is in-fractured using a Hill’s elevator. This allows easier access to the lateral
aspect or the inferior meatus. At this stage some surgeons use a
straight artery clip, placed along the length of the inferior turbinate
to crush the hypertrophied and vascular mucosa – but the authors
feel this is unnecessary if the nose is adequately prepared.
Turbinectomy scissors are then used to cut along the turbinate,
from anterior to posterior, staying as near the lateral nasal wall as
possible. The small posterior remnant of the turbinate is left in place.
The excised turbinate is then removed using forceps. The suction
diathermy (see above) is then introduced, with the distal end bent
at an angle of around 15°. With adequate suction, the whole length
of the turbinate is cauterised until haemostasis is achieved. The contralateral side is then completed in the same way and Naseptin
cream is applied to the turbinate stump.
The major potential complication is primary haemorrhage.
Dryness, crusting, synaechiae formation, excessive secretions, foul
discharge, bone exposure, osteitis, empty nose syndrome (atrophic
rhinitis) and epiphora are also recognised complications. Rare neurological sequelae include greater palatine nerve dehiscence and
partial oculomotor and trigeminal nerve palsy.7
Confining the trimming to the anterior and middle parts of the
inferior turbinate offers the advantage of lower incidence of haemorrhage.8
Post-op period
There is no requirement for routine post-operative nasal packing.
The patient is discharged the following day on regular saline douches,
Xylometazoline 0.1% for one week and oral analgesia. The patient is
reviewed after two weeks to remove the crusting and at further
two-weekly intervals until the crusting is minimal.
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Rare neurological sequelae include
greater palatine nerve dehiscence
and partial oculomotor and
trigeminal nerve palsy
Our experience
The senior author has performed 142 procedures between April
2003 and June 2007. Two patients developed secondary bleeding
that settled with conservative management. There are no reports of
cases of atrophic rhinitis documented in these patients. References
1. Juniper EF. Impact of upper respiratory allergic
diseases on quality of life. J Allergy Clin Immunol. 1998;101(suppl):S386-91.
2. Dowley AC, Homer JJ. The effect of inferior turbinate hypertrophy on nasal spray
distribution to the middle meatus. Clin. Otolaryngol. 2001;26:488-90.
3. Passali D, Passali FM, Damiani V, Passali GC, Bellussi L. Treatment of inferior
turbinate hypertrophy: A randomized clinical trial. Ann Otol Rhinol Laryngol.
2003;112:683-8.
4. Martinez SA, Nissen AJ, Stock CR, Tesmer T. Nasal turbinate resection for relief of
nasal obstruction. Laryngoscope 1983;93:871-5.
5. Padgham N, Vaughan-Jones R. Cadaver studies of the anatomy of arterial supply to
the inferior turbinate. J R Soc Med. 1991;12:728-30.
6. Berger G, Hammel I, Berger R, Avraham S, Ophir D. Histopathology of the inferior
turbinate with compensatory hypertrophy in patients with deviated nasal septum.
Laryngoscope 2000;110:2100-5.
7. Magarey MJR, Jayaraj SM, Saleh HA, Sandison A. Ball valve nasal obstruction following incomplete inferior turbinectomy. J Laryngol Otol. 2004;118(2):146-7.
8. Garth RJ, Cox HJ, Thomas MR. Haemorrhage as a complication of inferior turbinectomy: a comparison of anterior and radical trimming. Clinical Otolaryngology
& Allied Sciences 1995;20(3):236-8.
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