Radiofrequency Turbinate Reduction

Updated: Feb 18, 2016
  • Author: Belachew Tessema, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Overview

Overview

The most common reason for nasal obstruction is mucosal hypertrophy of the inferior turbinate, followed by structural deformity of the nasal airway (septal deviation, bony inferior turbinate hypertrophy). [1] Numerous interventions are available for the treatment of nasal obstruction secondary to inferior turbinate hypertrophy including medical treatments (immunotherapy, antihistamines, intranasal corticosteroid sprays, decongestants) and surgical options (corticosteroid turbinate injections, cryosurgery, electrocautery, turbinate out-fracture, microdebrider-assisted turbinoplasty, excision and submucous resection). The goals of inferior turbinate surgery include volume reduction, a reduction in nasal obstruction, and maintenance of nasal function while minimizing complications. There is currently no consensus on the most effective technique.

Radiofrequency turbinate reduction (RFTR) is a minimally invasive surgical option that can reduce tissue volume in a precise, targeted manner. This technique uses radiofrequency to create lesions within the submucosal tissue of the turbinate, reducing tissue volume with minimal impact on surrounding tissues. [2, 3] Radiofrequency turbinate reduction differs fundamentally from traditional methods by using low-power radiofrequency energy to provide a relatively quick and painless procedure for tissue coagulation.

An explanatory video of the procedure is below.

Radiofrequency turbinate reduction. Image courtesy of Gyrus ACMI-ENT.

The video below depicts RFTR being performed.

In this patient, stacked anterior lesions are placed under local anesthesia in the clinic. Topical aerosolized lidocaine was administered; 1% lidocaine with 1:100K epinephrine was slowly injected into the turbinate. Two lesions were placed on this side. Ideally, the lesion is placed slightly deeper to avoid the mild mucosal ischemia seen toward the end of energy delivery. Video courtesy of Vijay R Ramakrishnan, MD.

There have been multiple studies completed analyzing the outcomes of radiofrequency ablation (RFA) turbinate reduction. In 2009, Hyotnen et al completed a systematic literature review of the RFA technique and concluded that overall, the technique is well tolerated and effective. [4]

Additionally, multiple reviews comparing RFA with microdebrider-assisted inferior turbinoplasty (MAIT) have been published. Lui et al showed no statistically significant difference in outcomes between the techniques at 6 months; however, maintenance of improvement at 3 years was significantly better in the MAIT group. [5] Results also suggest that although RFA and MAIT both result in a statistically significant reduction in nasal blockage, MAIT is more effective in decreasing nasal volume. [6] Studies focusing on how RFA affects nasal histology report an increase in mucociliary times and loss of nasal sensation. [7, 8] Despite these reports of unfavorable effects, more research is needed, given the short follow-up times and earlier studies reporting no histologic changes. [9]

Overall, RFA has a low complication rate and has been shown to reduce nasal obstruction secondary to inferior turbinate hypertrophy; however, recently published studies suggest advantages to microdebrider turbinoplasty.

Relevant Anatomy

The lateral nasal walls contain 3 pairs each of small, thin, shell-like bones: the superior, middle, and inferior conchae, which form the bony framework of the turbinates. Lateral to these curved structures lies the medial wall of the maxillary sinus.

Inferior to the turbinates lies a space called a meatus, with names that correspond to the above turbinate, eg, superior turbinate, superior meatus. The roof of the nose internally is formed by the cribriform plate of the ethmoid. Posteroinferior to this structure, sloping down at an angle, is the bony face of the sphenoid sinus.

For more information about the relevant anatomy, see Nasal Anatomy.

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Indications

Radiofrequency inferior turbinate reduction can be used in patients with the following conditions: [2, 10, 11, 12, 3, 17, 13, 14]

  • Nasal congestion and rhinorrhea associated with inferior turbinate mucosal hypertrophy
  • Nasal congestion with inferior turbinate mucosal hypertrophy with a mildly deviated septum
  • Sleep apnea with increased nasal resistance and difficulty wearing a nasal CPAP mask
  • Inferior turbinate mucosal hypertrophy undergoing septoplasty, rhinoplasty, or endoscopic sinus surgery
  • Rhinitis medicamentosa requiring adjunctive treatment
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Contraindications

No absolute contraindications exist for radiofrequency turbinate reduction. However, the use of the radiofrequency turbinate reduction system is contraindicated in patients with heart pacemakers or other electronic devices unless they can be temporarily deactivated.

Patients with significant systemic comorbidities, such as hypertension or diabetes mellitus, may need special treatment adjuncts in conjunction with their primary care physician prior to undergoing radiofrequency turbinate reduction. Moreover, anticoagulant therapy cessation for 72 hours prior to treatment is necessary. [15]

Factors that may have an influence on the overall success of the radiofrequency turbinate reduction include the following:

  • Severe nasal and/or septal deformity
  • Acute allergic or infectious rhinitis
  • Active respiratory infection
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Anesthesia

See the list below:

  • When the procedure is performed with the patient awake, topical lidocaine 4% and a vasoconstrictor (eg, phenylephrine HCl) are applied via spray to each nasal cavity, followed by injection of 1 mL 1% lidocaine with 1:100,000 epinephrine into each inferior turbinate.
  • If the procedure is performed during another nasal procedure with the patient under general anesthesia, the topical lidocaine is omitted. [10, 15, 11]
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Equipment

Equipment includes the following: [15]

  • Handpiece
  • Cable
  • Dispersive electrode
  • Syringe, 3 mL
  • Needle, 25-30 gauge, 1.5 inch
  • Gauze
  • Nasal pledgets
  • Topical and local anesthetic/decongestant medications
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Positioning

See the list below:

  • For the stand-alone procedure, seat the patient comfortably in an examination chair with dispersive electrode placed over a well-vascularized muscular site (eg, lower back or lateral scapula) with full contact to the skin.
  • When performed in the setting of another nasal surgery, no special positioning is required.
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Technique

See the list below:

  • Insert the handheld needle electrode into the anterior portion of the inferior turbinate, as shown.
    Electrode insertion into anterior portion of the i Electrode insertion into anterior portion of the inferior turbinate. Image courtesy of Gyrus ACMI-ENT.
  • Insert the needle electrode into the middle portion of the inferior turbinate from an inferomedial approach to deliver 350-500 joules, 2-10 watts, and 70-80 volts, with a target temperature of 80°C per lesion. The activated system usually takes 2 minutes per lesion.
  • The depth of insertion should be 5 mm to reduce the risk of damage to the mucosa, causing ulcerations or sloughing.
  • Several options are available to create lesions within the inferior turbinate in order to achieve technique options (see corresponding images below). [15]
    • Single anterior lesion
      Single anterior lesion. Image courtesy of Gyrus AC Single anterior lesion. Image courtesy of Gyrus ACMI-ENT.
    • Anterior and mid lesions
      Anterior and mid lesion. Image courtesy of Gyrus A Anterior and mid lesion. Image courtesy of Gyrus ACMI-ENT.
    • Stacked anterior lesions
      Stacked anterior lesions. Image courtesy of Gyrus Stacked anterior lesions. Image courtesy of Gyrus ACMI-ENT.
    • Stacked anterior lesions, mid lesion, and posterior lesion
      Stacked anterior lesion, mid lesion, and posterior Stacked anterior lesion, mid lesion, and posterior lesion. Image courtesy of Gyrus ACMI-ENT.
    • Anterior, mid, and posterior lesions (4-lesion procedure)
      Anterior, mid, and posterior lesions (4-lesion pro Anterior, mid, and posterior lesions (4-lesion procedure). Image courtesy of Gyrus ACMI-ENT.
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Pearls

See the list below:

  • Placement of the needle too superficially may result in damage to the mucosa, including ulceration or sloughing of mucosal tissue.
  • If the lesion takes more than 2 minutes to form, the needle electrode may be too close to the conchal bone.
  • If the turbinate is enlarged in the anterior and mid-portion, 4 row lesions are recommended.
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Complications

See the list below:

  • Patients may experience mild to moderate pain during treatment of the posterior inferior turbinate. This can be controlled with additional local anesthetic injection.
  • Mild-to-moderate edema with subsequent nasal obstruction and thick mucus formation can be expected for the first week after the procedure.
  • If mucosal erosion is present, the risk of postoperative bleeding and adherent crust formation increases. [16]
  • If performed along with a septoplasty, scar tissue may form between the turbinate and the septum.
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