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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 11-15

Comparison of different surgical treatment modalities for nasal obstruction caused by inferior turbinate hypertrophy


1 Department of Surgery, College of Medicine, King Faisal University, Al Ahsa, Saudi Arabia
2 Department of Medical Intern, College of Medicine, King Faisal University, Al Ahsa, Saudi Arabia
3 Department of Neurosurgery Resident, King Fahad Hospital Hofuf, Al Ahsa, Saudi Arabia

Date of Submission01-Sep-2020
Date of Decision10-Oct-2020
Date of Acceptance02-Dec-2020
Date of Web Publication06-May-2021

Correspondence Address:
Njood Alaboud
Medical Intern, College of Medicine, King Faisal University, Al Ahsa
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJOH.SJOH_39_20

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  Abstract 


Background: Hypertrophied inferior turbinates considered the second most frequent contributor to nasal obstruction after septal defects. Various medical measures can be used to treat inferior turbinate hypertrophy (ITH). After failure of medical methods, surgery becomes the cornerstone of management, which is still a controversial issue in the otorhinolaryngology field. Although these surgeries have been practiced for decades, no conclusion has been drawn about the best and optimal choice. Objectives: The objectives were to compare the results between submucosal diathermy (SMD) and partial inferior turbinectomy (PIT) in terms of postoperative bleeding, crusting, dry throat, voice change, postnasal drip, nasal obstruction, need for re-use of medications, and further need for nasal surgery. Subjects and Methods: A prospective observational study involving 100 patients with ITH. Patients were randomly divided into two groups: Group A underwent SMD and Group B underwent PIT. Postoperative follow-up was done at 1 week, 1 month, and 6 months. Results: At 1-week, nasal crusting, postnasal drip, and dry throat were reported more in SMD. At 1-month, nasal crusting and voice change were experienced more in PIT. At 6-month, nasal crusting and voice change occurred more in PIT. Nasal obstruction occurred more in SMD. Re-use of medications and further nasal surgery were more in SMD. Conclusion: SMD is less invasive with fewer complications regarding bleeding and crusting in comparison to PIT, but its effectiveness compared to PIT in re-use of medications and need for further nasal surgery is less.

Keywords: Inferior turbinate hypertrophy, partial inferior turbinectomy, submucosal diathermy


How to cite this article:
Al Jabr IK, Alaboud N, Al Habeeb FA. Comparison of different surgical treatment modalities for nasal obstruction caused by inferior turbinate hypertrophy. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:11-5

How to cite this URL:
Al Jabr IK, Alaboud N, Al Habeeb FA. Comparison of different surgical treatment modalities for nasal obstruction caused by inferior turbinate hypertrophy. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jun 25];23:11-5. Available from: https://www.sjohns.org/text.asp?2021/23/1/11/315574




  Introduction Top


Nasal turbinates are important bony structures that protrude into the nasal passages and covered by mucosa.[1] These small structures contribute greatly to the normal respiratory function; they act like “resistors” by providing enough resistance which is an essential part of normal breathing. Their shape offers a good factor for increasing the surface area of the mucosa which is needed for purifying, warming, and humidification of the air.[2],[3]

Hypertrophied inferior turbinates are considered the second most frequent contributor to nasal obstruction after septal defects.[4],[5] Nasal obstruction is likewise considered one of the most common symptoms faced by ear–nose–throat (ENT) surgeons.[6] In addition to its great impact on patients' health and life, it has been described as a major economic burden with 5 billion dollars being spent yearly on relieving the nasal obstruction.[6],[7]

Different pathological processes can lead to acute or chronic inferior turbinate hypertrophy (ITH), these include allergic rhinitis, hormonal rhinitis, vasomotor rhinitis, infectious rhinitis, and rhinitis medicamentosa.[7] Variation in which parts of inferior turbinate are responsible for the hypertrophy has been described with the involvement of bone only, mucosa only, or the osseous part with mucosa together.[8] Various medical measures can be used to treat ITH including saline nasal sprays, antihistamines, sympathomimetic drugs, topical and systemic steroids, and avoidance of the allergen.[8]

However, if these techniques fail, the cornerstone of the management is surgery, which is still a controversial issue in the otorhinolaryngology field.[9],[10] After the first surgical reduction of inferior turbinate made by Hartmann, multiple surgical modalities have been introduced, including partial inferior turbinectomy (PIT), submucosal diathermy (SMD), turbinoplasty, CO2 laser vaporization, and radiofrequency ablation. Although some surgical options showed better results than others, no clear conclusion has been drawn about the optimal choice.[7]

It appears that the choice is made according to the preferred surgeon's experience, ENT examination, and hospital facilities. Therefore, this study aims to compare the postoperative outcomes of PIT and SMD.


  Subjects and Methods Top


A prospective observational study was done in the department of ENT at a tertiary hospital in Al Ahsa, Saudi Arabia, from January 2017 to December 2019 to evaluate the effects and complications of SMD and PIT. The prior approval of the Research Ethics Committee, King Faisal University, College of Medicine, was acquired to conduct this research.

This study involved a total of 100 patients from age 18 years to 47 years, with a mean age of 31.40 years. Patients were 55 females and 45 males involved in this study. Patients were randomly divided into two groups using simple randomization and informed consent was obtained from all patients: Group A underwent SMD and Group B underwent PIT each having 50 patients.

In this study, we included patients with clinical findings of ITH causing nasal obstruction who failed to respond to conservative treatment, including steroid nasal sprays, systemic antihistamine, and normal saline nasal irrigation. We excluded patients with gross deviated nasal septum which nearly cause a total obstruction, active nasal or sinus infection, enlarged obstructing adenoid, nasal polyp, septal perforation, and bleeding disorders and patients who refuse surgery or unfit for surgery or had a previous nasal operation.

A history was taken and clinical examinations were done for all patients by one surgeon. Besides, routine preoperative investigations were done for every patient: rhinoscopy, diagnostic nasal endoscopy, and radiologically by computed tomography scan of paranasal sinuses and basic laboratory investigations were done before surgery. All the patients were operated under general anesthesia. Following the procedure, anterior Merocel nasal packing was done for 24 h with antibiotics, analgesics, and nasal saline irrigation. Postoperative follow-up was done at 1 week, 1 month, and 6 months to assess and evaluate bleeding, nasal obstructions, crusting, dry throat, voice change, postnasal drip. In addition, the need for re-use of medications and the need for further surgery were assessed after 6 months.

We considered patients who had fresh nasal bleeding at postoperative follow-up as positive for nasal bleeding. Voice change considered positive in patients who perceived it by themselves.

All statistical data were analyzed using the Statistical Packages for the Software Sciences (SPSS) version 21 (SPSS, Armonk, NY: IBM Corp., USA). P < 0.05 has been accepted as the significance level for all statistical tests.


  Results Top


Of 100 patients included in this study, 55 patients were female, while males were 45 patients. Regarding the type of surgery, 50 (50%) patients underwent SMD and 50 (50%) patients underwent PIT. Twenty-four males underwent SMD and 21 males underwent PIT. While 26 females underwent SMD, and 29 females underwent PIT [Table 1].
Table 1: Gender and type of surgery

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Regarding the type of surgery and postoperative complications at 1-week follow-up, there was a significant difference in terms of nasal crusting, postnasal drip, and dry throat, (P = 0.0100), (P = 0.006), and (P = 0.001) (P < 0.05), respectively, in which all of them were reported more in patients who underwent SMD [Table 2].
Table 2: Comparison between the type of surgery and postoperative complications at 1 week

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Based on the results, it was revealed at 1-month postoperative follow-up, there was a statistically significant difference in nasal bleeding, nasal crusting, and in voice change, (P = 0.0009), (P = 0.0013), and (P = 0.037) (P < 0.05), respectively. They were experienced more in patients who underwent PIT [Table 3].
Table 3: Comparison between the type of surgery and postoperative complications at 1 month

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When it comes to 6-month postoperative follow up, nasal crusting and voice change occurred more in patients who underwent PIT with a significant P value (P = 0.0110) and (P = 0.012) (P < 0.05), respectively. On the other hand, nasal obstruction, occurred more in patients who underwent SMD (P = 0.021) (P < 0.05) [Table 4].
Table 4: Comparison between the type of surgery and postoperative complications at 6 months

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The re-use of medications was also more in patients who underwent SMD with a significant P value (P = 0.028) (P < 0.05). The need for further nasal surgery was more in patients who underwent SMD (P = 0.010) (P < 0.05), while none of the patients who underwent PIT needed further nasal surgery [Table 5].
Table 5: Comparison between the type of surgery and the re-use of medications and the need for further nasal surgery

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  Discussion Top


Nasal obstruction is considered one of the most common presenting complaints of patients attending the ENT clinic. Hypertrophy of inferior turbinate is a common leading cause of nasal obstruction.[6] After the failure of medical therapy, surgery becomes the treatment choice of hypertrophy of inferior turbinate. Surgical procedures are controversial, and many procedures have been used.[9],[10] As a result, the procedures can destroy the turbinate mucosa which leads to the loss of turbinate function and leads to bleeding and crusting. However, if only little tissue is removed, the nasal obstruction will persist. This study was done to evaluate and compare the efficacy and postoperative complications of SMD and PIT in the treatment of ITH.

In a study conducted by Imad et al., It was found that 40% of PIT patients had bleeding, while only 3% of SMD patients had nasal bleeding.[11] The study done by Al-Baldawi revealed that reactionary nasal bleeding was 12.5% in patients who underwent PIT, while none of the patients who underwent SMD had a reactionary nasal bleeding.[12] A study conducted by Vishnu and Rajamma revealed that reactionary nasal bleeding on postoperative day 1 was 43.3% of PIT patients.[13] Only 10% of SMD patients had a reactionary nasal bleeding. In our study, the incidence of bleeding was assessed at various times in both groups. During the 1st week, nasal bleeding was reported more by patients who underwent PIT patients, but there was no statistically significant difference. After 1 month, the difference was statistically significant, nasal bleeding was reported more by patients who underwent PIT. After 6-month postoperative follow–up, the percentage of bleeding decreased in both the groups with no statistically significant difference.

In this study, nasal crusting was more in patients who underwent SMD at the end of 1 week. However, the incidence of nasal crusting was decreased at 1-month and 6-month postoperative follow-up with this group. On the other hand, patients who underwent PIT had increased in had increased incidence of nasal crusting. In the long-term follow-up after 6 months, nasal crusting was reported more by patients who underwent PIT which was statistically significant between both groups at all periods of postoperative follow-up. However, another study found that PIT has crusting more than SMD at 1-week follow-up (21, 84%) of PIT patients while only 12 (48%) of SMD patients.[12]

In our study, dry throat was reported more by patients who underwent SMD than patients who underwent PIT at 1-week postoperative follow-up which was statistically significant. However, in the long term, there was no statistically significant difference between the two groups.

In this study, at 1-week postoperative follow-up, voice change was reported more in patients who underwent SMD. However, at 1-month postoperative follow–up, the percentage decreased in SMD patients where it increased in PIT patients. Besides, at 6-month postoperative follow–up, patients who underwent PIT reported voice change more. This was statistically significant at 1-month and 6-month postoperative follow-up. Furthermore, similar to our finding, a study was done by A Rao al found that no one of 30 patients who underwent SMD had a voice change at 3-week, 6–week, and 6-month follow-up, while another group (PIT) 3 of 30 cases reported voice change at 3 weeks and 2 cases at 6 weeks and 6 months.[14]

At 1-week and 1-month postoperative follow-up, there was no statistically significant difference between both groups in regard to nasal obstruction. However, at 6 months, the group of patients who underwent SMD had more nasal obstruction than patients who underwent PIT, which was statistically significant. In the long-term follow-up, PIT was found to be more effective in regard to nasal obstruction. Our results are supported by a study done by Aboulwafa et al., who found that PIT was more effective in reducing the nasal obstruction along with time than in the SMD group which had higher recurrence at 6-month postoperative follow-up.[15] Besides, this was in accordance with other studies by Kafle, at 6-month postoperative follow-up, six patients who underwent SMD had a recurrence of nasal obstruction and in patients who underwent PIT, none had a recurrence.[16] This is the same line with our findings that in the long-term PIT is better than SMD. However, a study by Gomma concluded that there was no statistically significant difference between SMD and PIT in nasal obstruction improvement throughout 3-month postoperative follow-up period.[17]

In our study, we found that postnasal drip was statistically significant only at 1-week postoperative follow–up, it was more in patients who underwent SMD than the patients who underwent PIT. At 1 month and 6 months, there was no difference between both the groups in regard to postnasal drip.

A study about endoscopic inferior turbinate reduction procedure outcomes done on 28 patients by Gupta et al. found that the re-use of medications was 25% of patients used nasal steroids, 21% used oral decongestants, and 11% used nasal decongestants.[18] Moreover, no patients needed further nasal surgery. In this study, we evaluated the re-use of medications after surgery and the further need for nasal surgery in both the groups. The re-use of medications was more in patients who underwent SMD which was statistically significant. Furthermore, the SMD patients who need further nasal surgery six (12.5%) patients. However, no cases of PIT group needed further nasal surgery indicating better effectiveness in the long term.


  Conclusion Top


Based on our finding, PIT was more effective in relieving the symptoms of nasal obstruction and postnasal discharge as compared to submucosal diathermy. However, SMD was a better procedure in respect of complications such as bleeding and crusting. Our study recommends PIT as an effective technique for the treatment of ITH as no need for further nasal surgery for 6-month follow-up. Although this study provides important insight into postoperative complications and efficacy of SMD and PIT in treating ITH, we suggest future prospective studies with larger sample size and longer follow-up period and also to address further surgical options in terms of treating ITH.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Farmer SE, Eccles R. Chronic inferior turbinate enlargement and the implications for surgical intervention. Rhinology 2006;44:234-8.  Back to cited text no. 1
    
2.
Berger G, Balum-Azim M, Ophir D. The normal inferior turbinate: Histomorphometric analysis and clinical implications. Laryngoscope 2003;113:1192-8.  Back to cited text no. 2
    
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Hol MK, Huizing EH. Treatment of inferior turbinate pathology: A review and critical evaluation of the different techniques. Rhinology 2000;38:157-66.  Back to cited text no. 3
    
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Clark DW, Del Signore AG, Raithatha R, Senior BA. Nasal airway obstruction: Prevalence and anatomic contributors. Ear Nose Throat J 2018;97:173-6.  Back to cited text no. 4
    
5.
Scheithauer MO. Surgery of the turbinates and “empty nose” syndrome. GMS Curr Top Otorhinolaryngol Head Neck Surg 2010;9:Doc03.  Back to cited text no. 5
    
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Jourdy D. Inferior turbinate reduction. Oper Tech Otolaryngol Head Neck Surg 2014;25:160-70.  Back to cited text no. 7
    
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Saulescu M, Sarafoleanu C. Surgery for nasal obstruction in inferior turbinate hypertrophy. Rom J Rhinol 2015;5:25-30.  Back to cited text no. 8
    
9.
Clement WA, White PS. Trends in turbinate surgery literature: A 35-year review. Clin Otolaryngol Allied Sci 2001;26:124-8.  Back to cited text no. 9
    
10.
Passàli D, Passàli FM, Damiani V, Passàli GC, Bellussi L. Treatment of inferior turbinate hypertrophy: A randomized clinical trial. Ann Otol Rhinol Laryngol 2003;112:683-8.  Back to cited text no. 10
    
11.
Imad, Javed, Sanaullah. Comparison of Submucosal Diathermy with Partial Inferior Turbinectomy: A Fifty Case Study. J Postgrad Med Inst 2012;26:91-5.  Back to cited text no. 11
    
12.
Al-Baldawi MH. Management of inferior turbinate hypertrophy: A comparative study between partial turbinectomy and submucous diathermy. Iraqi J Comm Med 2009;22:264-7.  Back to cited text no. 12
    
13.
Vishnu MS, Rajamma KB. Comparison of submucosal diathermy and partial inferior turbi nectomy. Int J Sci Stud 2016;4:120-3.  Back to cited text no. 13
    
14.
Rao BA, Veeraswamy N, Prasad TL, Chandra BS, Rao SS. A comparative study of different methods of treatment for inferior turbinate hypertrophy. J Evol Med Dent Sci 2016;5:2542-4.  Back to cited text no. 14
    
15.
Aboulwafa WH, Saad AE, Abbas AY, Elewa MA, Eldahshan TA. Comparative study between submucosal diathermy and endoscopic partial turbinectomy in hypertrophied inferior turbinate. Egypt J Hosp Med 2019;74:809-19.  Back to cited text no. 15
    
16.
Kafle P, Maharjan M, Shrestha S, Toran KC. Comparison of sub mucosal diathermy and partial resection of Inferior turbinate in the treatment of symptomatic nasal valve blockage. Kathmandu Univ Med J (KUMJ) 2007;5:501-3.  Back to cited text no. 16
    
17.
Gomaa MA, Abdel Nabi OG, Abdel Kerim AR, Aly A. Comparative study between partial surgical inferior turbinectomy and sub-mucosal diathermy of inferior turbinate for treatment of inferior turbinate hypertrophy. Otolaryngol 2015;5:217.  Back to cited text no. 17
    
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Gupta A, Mercurio E, Bielamowicz S. Endoscopic inferior turbinate reduction: An outcomes analysis. Laryngoscope 2001;111:1957-9.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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