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Table of Contents
REVIEW ARTICLE
Year : 2000  |  Volume : 2  |  Issue : 1  |  Page : 2-10

Approaches to the Hypertrophied Inferior Turbinate


Department of ENT, Security Forces Hospital, Riyadh, Saudi Arabia. Formerly Professor of Otolaryngology, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication6-Jul-2020

Correspondence Address:
MD, FRCS Siraj Mustafa Zakouk
Department of ENT Security Forces Hospital, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.289072

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How to cite this article:
Zakouk SM. Approaches to the Hypertrophied Inferior Turbinate. Saudi J Otorhinolaryngol Head Neck Surg 2000;2:2-10

How to cite this URL:
Zakouk SM. Approaches to the Hypertrophied Inferior Turbinate. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2000 [cited 2021 May 5];2:2-10. Available from: https://www.sjohns.org/text.asp?2000/2/1/2/289072




  Introduction Top


Nasal obstruction is a common complaint that frequently leads the patient to seek relief using medical or surgical means. Although it is not a life- threatening situation, however, it can make the patient quite miserable. The inferior turbinates (IT) are the main cause when septal deviations and other causes were excluded. Common causes o,f turbinate enlargements include allergic rhinitis, rhinitis medicamentosa, use of Rauwoflia drugs and hypothyroidism. An important frequent condition seen by ORL surgeons is the compensatoiy hypertrophy of the IT associated with nasal septal deviation that contributes to the obstruction already caused by the septal deviation. The IT take part in humidification, warming and filtration of inspired air. The airflow is changed by the shrinkage and enlargement of the IT. This contributes to the normal nasal cycle. [ 1 ] Normally, the IT do not obstruct breathing except occasionally when the person is reclining. In this condition, as blood and tissue fluid pool in the head, the person may find one or the other side of the nose is blocked. By turning over in bed, the dependant obstructive side becomes uppermost and the obstruction is relieved. Such alternating enlargement and shrinkage of the soft tissues of the turbinates occur several times a day regardless of posture but does not cause symptoms.[2] Enlargement of the inferior turbinate is usually bilateral in patients with allergic rhinitis and rhinitis medicamentosa. It is caused by thickening or engorgement of the turbinate without hypertrophy or any changes in the bony turbinate. This would explain the transient relieving effect of topical vasoconstrictor drops. Unilateral inferior turbinate hypertrophy is frequently associated with nasal septal deviation in the concave side. Hilberg et al[3] state that the hypertrophy in this condition may involve both the mucosa and the underlying bone. When the mucosa is only involved, septoplasty will usually result in return of the mucosa to its normal size. When the bone is involved, however, unilateral nasal obstruction will remain after septoplasty as the turbinates will not decrease in size and some form of reduction will be needed. The diagnosis of nasal obstruction requires awareness of the various conditions associated the IT. A good history taking and examination are obviously a prerequisite to pinpoint the cause. Examination of the nose should include endoscopy with and without the use of nasal decongestant . The endoscope allows the inferior turbinate to be examined in its entirety.

Tests for nasal functions are not well developed. Nasal expiratory or inspiratory peak flow, rhino- manometry, acoustic rhinometry and olfactory thresholds were used. Radiological examination preferably CT scan and cytologic examination of nasal smear and mucocilairy clearance measurements may be performed. Some of these tests are not available in every center and most physicians depend on the patientis symptoms, clinical examination and radiological assessment.

Treatment:

The primary aim of treatment is to reduce the size of the turbinate and thus maximize the nasal airway. It is also important that this aim is maintained for the longest period of time possible with the least side effects and complications. There are e two treatments modalities i.e. medical and surgical.

Medical Treatment:

Medical treatment should address the underlying diseases e.g. allergic rhinitis, rhinitis medicamentosa, sinusitis, hormonal imbalance. It will also help in differentiating the degree of obstruction caused by the disease from that caused by anatomical abnormalities e.g. deviated nasal septum. Medical treatment can be divided into pharma- cotherpay and non-pharmacoptherapy.

Pharmacotherapy:

Goode and Pribitkin [4 ] include the following as medical treatment: antihistamines, sympathomimetic drugs, anticholinergics, corticosteroids, sodium cromoglycate and expectorants. Nasal decongestants are effective in relieving nasal obstruction but cannot be given for long periods of time due to the danger of developing rhinitis medicamentosa. Oral decongestants are also effective but their contraindications should be addressed. Anticholinergics and sodium cromoglycate have no effect in reducing turbinate size and relieving nasal obstruction.

Corticosteroids, however, play a very important role in relieving nasal obstruction especially in allergic rhinitis. They can be administered topically or systemically.

All of these medications have variable effectiveness and are not free from side effects and complications,

Non-pharmacothcrapy:

Certain non-pharmacological measures might help in the reduction of the size of the turbinates and lead to improved airway. Goode and Pribitkin[4] list these as those measures that improve the environment by reducing allergens and irritants including moulds, dust and cigarette smoke. Proper room temperature and humidity can prevent dryness of the nose. Saline nasal douches can help by reducing dryness and removing crusts. Dehydration should be prevented by increasing fluid intake.

Surgical treatment:

Surgery should not be contemplated before medical treatment is tried. The trial of medical treatment helps to assure the surgeon that any residual enlargement of the turbinate that could not be relieved by non surgical means might be amenable to surgery. According to King and Mabry[5] many causes of turbinate enlargement are amenable to surgery e.g. allergic rhinitis, rhinitis medicamentosa, sinusitis, hormonal rhinitis and compensatory enlargement of turbinates. Inferior turbinate surgery to relieve nasal obstruction has been performed since a long time.[6] Surgical reduction of obstructing IT after failure of medical therapy remains a controversial subject. However, it seems that surgical reduction is the only effective method of treatment of the enlarged turbinate. The following are the methods used:

  1. Linear cautery
  2. Submucosal diathermy (SMD)
  3. Cryosurgery
  4. Injections of sclerosing agentsor steroids.
  5. Out-fracture of the inferior turbinate
  6. Vidian neurectomy.
  7. Turbinate resection Procedures:


  8. 7.1- Partial turbinectomy

    7.2- Total turbinectomy

    7.3- Turbinoplasty

    7.4- Laser turbinectomy

  9. Radiofrequency.


Linear cautery and Submucosal Diathermy:

These mathods depend upon the destruction scarring of the turbinate to reduce its size using electrical means. The cauterypoint is applied to the surface of the inferior turbinate in a linear manner starting from the posterior end and proceeding to its anterior end. Insubmucous diathermy the diathermy needle point is introduced into the substance of the turbinate and the current is applied as the needle is gradually withdrawn.

These are simple methods that can be performed under local anaesthesia and can be repeated as necessary since their therapeutic duration is short.

Cryosurgery:

Again this is a simple procedure that can be performed under local anaesthesia in an out-patient setting. Using a special cryosurgical probe the surface of the inferior turbinate is literally frozen.

Injection of scclrosing agents or Steroids:

The injection of sclerosing agents have been tried in order to reduce the size of the turbinate by production of obstruction to the vascular channels. This is not a popular method. Injection of steroids into the substance of the turbinates have been tried effectively, albeit, temporarily in cases of allergic rhinitis and rhinitis medicamentosa. This is a simple method that can be performed as an out-patient procedure. It can be repeated as required.

Out-fracture of the Inferior Turbinate; Concho- antropexy

This method depends on displacing the turbinate laterally in order to reduce its obstructing effect. It is again a simple procedure but its effects are small and temporary. Concho-antropexy is a procedure where the IT are outfractured into an inferior antrostomy.

Vidian Neurectomy:

This procedure was pioneered by Golding-Wood for the treatment of rhinorrhoea.[7],[8] The results regarding relief of nasal obstruction have been variable. This is a major surgical undertaking that requires hospitalization and general aneasthesia.

Tiirbinectomy:

The aim of this procedure is to reduce the bulk of the turbinate either totally or partially utilizing different techniques. Varying amounts of the free margin of the inferior turbinate is removed here.

Partial Inferior Turbinectomy:

As the name implies there is a partial removal of the substance of the turbinate here. This may also include a sliver of bone as well. Some authors advocate thc removal of only the anterior end of the turbinate.[9] Post-operative haemorrhage is a serious complication of this procedure.

Total or Radical Turbinectomy:

Here the inferior turbinate is removed İn its entirely flush with the lateral wall of the nose. It seems that radical turbinectomy produces better results than partial turbinectomy. Atrophic rhinitis, as a complication, can be troublesome especially in dry hot climates.

Turbinoplasty:

In this procedure the inferior turbinate bone is removed utilizing a submucous resection method. The overlying mucosa is left intact. It aims at preserving as much as possible of the mucosa of the turbinate and to seal the wound so as to avoid bleeding. Some authors[10] have used the endoscope while performing this procedure.

Laser Turbinectomy:

Here the laser is used to reduce the size of the turbinate. Various kind of lasers have been used. There are reports on the successful application of argon laser[ll] C02 laser[12],[13] the KTP laser[14] the Ho:Yag laser[15]the Nd:Yag laser[16],[17] and the magnet laser .[18] Little bleeding and tissue trauma are the main advantages . It can be performed as an out-patient procedure under local anaesthesia.

Radiofrequency ablation:

This is a minimally invasive technique that uses radiofrequency energy to reduce the turbinate tissue volume.


  Discussion Top


Inferior turbinate hypertrophy has not been clearly defined . Is it a hypertrophy in the pathological sense? or is it just a swelling ( engorgement, thickening, oedema)?. The word hypertrophy is always used İn the literature and will be kept here in our discussion. Hypertrophy of the inferior turbinate is a common cause of nasal airway obstruction more often than commonly thought.[19] The otolaryngologist is faced daily with this, sometimes, very difficult problem to deal with. The role of the IT in nasal obstruction is not easy to evaluate. There is no objective test that could be used to evaluate the effects of the turbinates on nasal obstruction conclusively and many depend on subjective reports of the patient in answering a questionnaire. The mucosa is the organ of the nose and removal of turbinate tissue can result in significant loss of normal nasal function over time. This loss includes disturbances in respiration and alteration in nasal defense mechanisms. Kern[20] present the concept of the “Empty Nose Syndrome” and relates its aetiology to the removal of functionening nasal tissue specially functional turbinate tissue. The syndrome consists of nasal obstruction, crusting, bleeding, recurrent infections, pain, disturbances of olfaction, nasal odour and depression. The otolaryngologist, when dealing with nasal obstruction due to hypertrophied IT, has to resort to medical means before contemplating surgery. Medical treatment as listed by Goode and Pribitkin[4] include antihistamines, sympathomimetic drugs, anticholinergics, sodium cromoglycate and corticosteroids.

Histamine is an important inflammatory mediator released from mast cells and basophils. It causes vessel dilatation and increased permeability. It stimulates the sensory nerve endings in the nose resulting in itching, sneezing and secretion.[21] Antihistamine are effective in reducing sneezing, itching and watery discharge but have no effect on nasal obstruction.

Nasal decongestants reduce nasal obstruction very quickly, but can be used only for short periods of time so as to avoid rhinitis medicamentosa.[22] Oral decongestants can be used for long periods but one has to bear in mind their side effects and contraindications. They may cause restlessness, sleep problems, agitation, tachycardia, angina pectoris, headache, hypertension and micturation problems.[23]

Anticholinergics may reduce watery rhinorrhoea but have no effect on nasal obstruction.[24] Sodium cromoglycate reduces itching, sneezing, secretion and nasal obstruction in allergic rhinitis and is used as a prophylactic drug. The use of corticosteroids for the relief of nasal obstruction specially in allergic rhinitis is well known. Topical steroids are effective in reducing nasal obstruction in allergic and non-allergic non- infective rhinitis.[25] Occasionally dryness of the nose, crusting and blood stained rhinorrhoea may occur. Septal perforation has been reported.[26] Systemic corticosteroids can be used in severe cases. They should be used with caution and in the absence of contraindications. Systemic corticosteroids should not be used in children and pregnancy.

Surgery should not be contemplated before medical treatment is tried. The trial of medical treatment helps to assure the surgeon that any residual enlargement of the turbinate that could not be relieved by non surgical means might be amenable to surgery. According to King and Mabry[5] many causes of turbinate enlargement are amenable to surgery e.g. allergic rhinitis, rhinitis medicamentosa, sinusitis, hormonal rhinitis and compensatory enlargement of turbinates.

Inferior turbinate surgery to relieve nasal obstruction has been performed since a long time.[6] Surgical reduction of obstructing IT after failure of medical therapy remains a controversial subject. Failure of medical treatment is always a challenge to the otolarygologist. Enlargement of the turbinates may be bilateral usually in cases of allergic rhinitis or rhinitis medicamentosa. It is caused by thickening or engorgement of the turbinate mucosa without hypertrophy or any changes in the bony part of the turbinate. This could explain the transient relieving effect of topical vasoconstrictor drops. Compensatory unilateral inferior turbinate hypertrophy is frequently associated with a deviated nasal septum. Hilberg et al[3] stated that the hypertrophy of the inferior turbinate in this condition may involve both the mucosa and the underlying bone. When the mucosa is only involved, septoplasty will result in return of the mucosa to normal or reduction in the size of the turbinate. But when the bone and mucosa are involved, unilateral nasal obstruction will remain after septoplasty as the turbinate will not decrease in size. The so called minimally invasive techniques to reduce the volume of the inferior turbinates has brought new tools but they do not solve the problem of indications for surgery in patients with nasal obstruction and hypertrophy of the turbinates.[27] According to King and Mabry[5]failure to address symptomatic turbinate hypertrophy is a major cause of a blocked nose after septoplasty. Linear cautery and submucous diathermy are used to reduce the volume of the inferior turbinate by destruction and scarring. They are easy to perform under local anaesthesia in the clinic and can be repeated as required. However, their effect is short lived, usually lasting months to years,[4] Warwick- Brown and Mark[28] reported that patient satisfaction after submucous diathermy with or without outfracture, linear cautery and even partial turbinectomy declined from 82% after one month postoperatively to 41% after one year.[28] Linear cautery results in oedema and crusting. Adhesions may occur in 20-30 percent of the cases,[29] Submucous diathermy and bipolar cautery can lead to inferior turbinate bone necrosis.[4] Delayed epistaxis may occur 5-10 days postoperatively. Thermal injury to other parts of the nose may also occur.

Outfracture of the turbinate is a safe mechanical means in reducing the obstructive symptom. Only minor improvement is noticed as the turbinate usually goes back to its original place. Moreover, it does not address the underlying pathology of hypertrophy.[4],[29] This procedure is often combined with other techniques. The application of cryosurgery to the inferior turbinate to alleviate nasal obstruction is a simple procedure that can be carried out under local anaesthesia as sji out-patient procedure. In this procedure minimal permanent damage is incurred and little scarring is produced.[5] Severe haemorrhage has been reported.[29],[30],[31] However, Principato[32] reported recently that among 1400 patients treated with cryosurgery no significant postoperative epistaxis was noted. The equipments for the procedure can add to the cost of turbinate therapy. The duration of relief is short lived and the procedure can be repeated as necessaiy. The duration of results are variable lasting from one year to almost perman<;nt,[4],[33]

Intraturbinal injection of steroids was first reported by Wall and Shure.[34] The procedure was further popularized by Simmons.[35] It is easy to perform as an out-patient procedure that can be repeated. It is quite effective İn producing temporary relief İn cases of allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa, rhinitis during pregnancy, sinusitis, large nasal polyps and at the and of intranasal surgery.[4],[36]

Mabry[37] observed the incidence of minor side effects in 11% of patients. Common side effects include transient facial flushing, blood stained rhinorrhoea, weakness and rarely myalgia. The most serious complication of intraturbinate steroid injection is temporary or permanent blindness[38],[39],[40],[41]

The injection of sclerosing agents into the substance of the inferior turbinate in order to reduce its size has been tried. Results have been variable.[31] This is not a popular method. Golding-Wood[7],[8] pioneered the technique of vidian neurectomy for cases of severe rhinorrhoea. Principato[31] describes moderately good results in relieving nasal obstruction and Sadanaga[42] reported 94.9% relief of nasal obstruction after vidian neurectomy. Vidain neurectomy is a major surgical undertaking that requires general anaesthesia. Dry eyes are a common postoperative complication due to denervation of the lacrimal gland.[42] Transient postoperative headache is another frequent complication which usually disappears in 3 weeks.[43],[44] The other complications that have also been reported include haemorrhage, numbness of the palate, teeth and cheek, maxillary sinusitis, ophthalmoplegia and even unilateral blindness.[43],[44],[45],[46],[47]

Partial inferior turbinectomy can involve removal of the IT in part or in whole. Partial simple turbinectomy is ea!sy to perform and the symptomatic relief is longer1; lasting but re-growth of turbinate tissue occurs. [4’j

Courtiss and Goldwyn[48],[49] show that with follow up ranging from 6 1/2 to 9 1/2 years,70 out of 76 patients believed their breathing remained better, six beliwed it was the same and none believed it was worse compared with their pre-operative condition. The amount of turbinate tissue to be removed can be altered according to the condition and climate, ι Post-operative complications occur more frequently with partial inferior turbinectomy than with thb other procedures discussed s far.Haemorrhage is reported by various authors be less than 1%[55] to as high as 10%. Bleeding can be immediate or delayed [51 ] ama c be severe enough to require blood transftision.pAj This complication requires the insertion of a nasa pack post-operatively which can increase the d’ comfort associated with the condition. Synechia and prolonged busting are relatively frequent.pj Atrophic rhiinitis is considered a more troublesom complication specially in hot dry climates. This fact is disputed by authors like Spector[53] Pollock and Rohrich[54] Fanous[52] and Courtiss and Goldwyn.[49].

Total inferior turbinectomy has been tried in the past and recently in some centers. It was previously condemned because of fears of subsequent development of atrophic rhinitis[55],[56] and associated significant morbidity[57],while other authors like Martinez et al[58]and Ophir[59] reported minimal complication rate following this procedure. Total inferior turbinectomy entails removal of the entire inferior turbinate flush With the lateral nasal wall. When comparing total turbinectomy with partial turbinectomy , the benefits and risk are very similar. Total turbinectomy is easier to perform. Salam and Wengraf[60] reported results of comparison between total inferior turbinectomy (TIT) and concho-atropexy(CAP), They concluded that there were no significant statistical difference between CAP & TIT in relieving nasal obstruction and discharge due to hypertrophy of the inferior turbinates (P>0.5) but TIT was associated with more postoperative pain(P>0.05), long term dryness and crusting (P>0.05) which were statistically significant. Ophir et al[61] reported that a long term follow up of the effectiveness and safety of inferior turbinectomy in 186 patients with a 10 to 15-years follow up period (mean 12.3 years) demonstrated subjective relief of nasal obstruction in 82% of patients and widely patent nasal airways upon rhinoscopy in 88% of patients. They claim that they did not observe atrophic changes of the nasal mucosa or chronic infection in any of their patients. Wight et al[62] concluded that the more radical procedure produced better results.

Ophir et al[61] noted that 16 out of 32 patients with pre-operative bronchial asthma had improvement in their symptoms, whereas three had exacerbation of their condition. White and Murray[63] in a retrospective study of case records found that 30.8% of patients undergoing turbinectomy alone required formal divisions of dense adhesions. Turbinectomy in children was reported by Thompson[64] to be a safe and effective procedure. His series were small; 22 children below 15 years of age. The postoperative period was between 9.5 to 51 months ( mean 26 months). The procedures performed ranged from limited trimming of the free mucosal edge to radical reduction of the inferior turbinate with removal of all obstructing soft tissue and underlying bone, intranasal adhesions were not seen in these children following turbinate resection. This is also the experience of others.[l,61]

Mabry[65] argues that submucous resection of the turbinate is enough to alleviate the obstruction associated with stromal hypertrophy and/or posterior tip enlargement. In an early report Mabry[66] did not observe postoperative crusting in patients who underwent turbinoplasty at I to 3-year follow up and there were no postoperative bleeding requiring repacking. At a further follow up, Mabry[65] reported no evidence of rhinitis sicca or atrophic rhinitis İn any of his patients. According to Grymer et al[67] turbinoplasty resulted in improvement in nasal patency in 93% of 42 patients, 20 of them had complete satisfaction and a persistent feeling of obstruction was found in 11 patients. The main disadvantage of submucous resection techniques is that they are difficult to perform. Even though the incidences of crusting and bleeding are reduced, potential complications still remain. Post-operative packing is still required in these cases. Return of nasal obstruction was noted in 25% of Mabry’s[65] patients at 39 and 63 months postoperatively after inferior turbinoplasty. Mucosal sparing, which is maximized in inferior turbinoplasty may contribute to persistent post-operative rhinorrhoea or postnasal discharge as reported by Katz et al.[68] Marks[10] observes that endoscopic turbinoplsty employing the endoscope has the advantage of improved visualization, allowing the resection to be precisely tailored.

Lasers was introduced to intranasal surgery in the 1970s and since then a number of procedures have been introduced to treat nasal obstruction. The use of different lasers for the treatment of inferior turbinate hypertrophy have been extensively reported; carbon dioxide laser[12],[13],[69],Nd:YAG laser[16],[17] 5KTP/532 lasers[14],[70] holmium: YAG laser[15],[71]diode laser[72] magnet laser.[18] Laser treatment has many advantages. It can be performed under local anaesthesia as an out-patient procedure(46,47), excellent intraoperative haemostasis[46],[48],[49] and does not need postoperative packing(49,50).

Lippert and Werner[80] report patientis satisfaction to be 80.4% at 2 years post-opratively while Kawamura et al (47) obtained 85% excellent or good results at 2 years postoperatively. Most authors recognize the efficacy of laser treatment of the inferior turbinate regardless of the of the type of laser used.

Eschar formation which may cause postoperative obstruction and rarely haemorrhage with sloughing of eschar has been reported.[5] Considerable postoperative crusting typically occurs for 6-8 weeks which requires frequent out-patients visits.[29] for removal. Synechiae may occur in addition to the general hazards of laser use. Laser is only effective in removing mucosal hypertrophy and is not effective in removing underlying bone. Finally the equipment is expensive and the use of laser requires special training.

Recently a minimally invasive technique using radiofrequency energy to reduce tissue volume has been reported.[73],[74],[75] Radiofrequency energy delivered submucosally to the inferior turbinate creates a thermal lesion (80°C) yet preserves mucosa. The energy is measured m joules; and about 400 joules is used in the nose. It relies on verv low levels of frequency energy t 465KHZ).The circumscribed area of submucosal necrosis is replaced overtime by f.brob asts as part of the normal wound repair process. Wound contraction results in turbinate volumetric reduction, leading to relief of nasal obstruction. The device operates at low power (92-10 watts) and low voltage (80 volts). Radiofrequency tissue ablation (RFTA) differs from electrocautery which is applied at very high voltage ( upto 800 volts). RFTA only raises the tissue temperature to 60-90°C range, limiting heat dissipation and damage to adjacent tissues. In contrast, tissue temperatures generated by electrocautery, diathermy or laser energy are significantly higher(750-990°C) and can result in heat propagation in excess of therapeutic need, injuring surrounding tissues. The use of RFTA in the nose is limited to few centers at the moment. Crusting, synechiae and epistaxis are reported.[76] however, Li et al[73]report minimal adverse effects.Utley et al[75] report mild to moderate oedema with subsequent nasal obstruction and thick mucoid rhinorrhoea in all of their patients at 1 week and in one patient at 8 weeks. The equipments and the concomitant use of disposables are expensive and training in its use is required. Additional studies are needed to determine the period of improvement of nasal airway. Few comparative studies are available that compare different surgical techniques and their effect on relieving nasal obstruction.Wight et al[62] compare anterior and radical trimming of the inferior turbinate in 18 patients. They note that radical trimming produced a significant decrease in both total nasal resistance to airflow and subjective nasal obstruction. Anterior trimming on the other hand produced a significant decrease in total resistance to air low but had no significant effect on subjective nasal obstruction. Hence, they do not recommend anterior trimming. Meredith[76] compared electrocoagulation-outfracture to partial inferior turbinate resection in 200 patients. McCombe et al[77] compared the effect of laser cautery ( Co2 laser )to sub-mucosal diathermy on the inferior turbinate in 29 patients. Subjective and objective measurements of airway obstruction were performed using a linear analogue scale and nasal inspiratory peak flow meter. They report a simUa and significant improvement in the «Vkîi .· score at 6 weeks. They also report hat ΪΓ tıve scores improved equally ζ Wh VmV Τ were not significant. Salam and Wenmf ff ^ pared concho-antropexy to totaMnSfc tomy in 25 patients. They found no significant statistical difference in the efficacy of these two procedures in relieving nasal obstruction. Furthermore, total inferior turbinectomy was associated with more postoperative pain and with long-term dryness and crusting.

Rakeover and Rosen[78] compared partial inferior turbinectomy with cryosurgery in 52 patients. Among those who underwent partial inferior turbinectomy good nasal patency was obtained in 77% of patients at 2-5 years postoperatively while those with cryosurgery showed good relief of nasal obstruction in 35% of patients at 2-5 years postoperatively. More complications were reported with partial inferior turbinectomy as compared to cryosurgery.

Elwany and Harrison[69] compared partial inferior turbinectomy, inferior turbinoplasty, cryotur- binectomy and laser turbinectomy in 80 patients. Those who underwent partial inferior turbinectomy and laser turbinectomy reported better results regarding relief of nasal obstruction (75% and 80% respectively at the end of none year). The other group of inferior turbinoplasty and cryturbinecto- my had 50% and 45% relief of nasal obstruction at one year respectively. When comparing the relative morbidity of the partial inferior turbinectomy and laser turbinectomy, Elwany and Harrison[69] reported that laser turbinectomy was only associated with postoperative synechiea. On the other hand partial inferior turbinectomy was associated with postoperative heamorrhage, atrophic changes and longer hospital stay. They conclude that the results of partial inferior turbinectomy and laser turbinectomy were superior to those of turbinoplasty and cryoturbinectomy.

Passali et al[79] randomly compared electrocautery, crysurgery, laser, submucosal resection without lateral displacement, submucosal resection with displacement and turbinectomy. They suggest that submucosal resection with lateral displacement of the inferior turbinate offers the greatest increase in airflow and nasal respiratory function with low long term complication rate. Passali et al[79] recommend this method as a first choice operation for the hypertrophied IT causing nasal obstruction.

Lippert and Werner[80] compared 533 patients with inferior turbinate hypertrophy treated by various carbon dioxide and neodymium:yttrium-aluminum-gamet laser techniques, They also compared their results using lasers with those of SMD According to them the CO2 laser produced little bleeding or any pain. It produced effective: results in few days, By contrast the success of Nd:YAG laser became evident after weeks or months. Compared with SMD, both laser methods produced better long term results.


  Conclusion Top


Nasal obstruction caused by hypertrophied IT seems to be a real problem that can be perplexing to the practicing otolaryngoloist. There are various methods to deal with this problem. It is always advisable to try medical treatment first before under taking any surgical endeavors. When contemplating surgery, one has to think about the predisposing factors and their treatment. There is a large volume of literature regarding the different means of dealing with the IT and the pros and cons of each one of them. The surgeon has to tailor the technique he intends to use to the demands of the patientis condition. It is advisable to always be conservative when operating on the IT and more so if children are involved. The treatment should strive to minima! morbidity and maximum benefits.

Although the literature is full of papers that deals with different methods of treatment of the hypertrophied turbinates, but is sparse in comparative studies. There is a need for controlled, prospective comparative studies dealing with these different treatment modalities.



 
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