Turbinectomy Technique

Updated: Mar 01, 2016
  • Author: Philip E Zapanta, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Technique

Approach Considerations

In the author’s practice, the author commonly uses 2 methods of inferior turbinate reduction: soft tissue reduction versus a true submucous resection of the inferior turbinate bone. During the author’s initial clinical assessment of the patient, the author will first perform anterior rhinoscopy without topical decongestants. The author takes note of the septum and its shape and the turbinate size with its mucosal health. Then the author sprays topical decongestant (oxymetazoline) and reassesses the nasal airway with the anterior rhinoscopy and nasoendoscopy.

The author documents if the turbinate mucosa responded to the decongestant and assesses how much the airway was obstructed before and after the decongestant. Some insurance carriers require that this be documented clearly in the patient’s chart. The author repeats this whole process on the operating table after intubation and prior to the actual surgery.

If the turbinate mucosa responded well to the decongestant, and the soft tissue appears to be playing a significant role, the author uses a 2.0 mm inferior turbinate blade (Medtronic) to reduce the turbinate (soft tissue reduction only). If the inferior turbinate is still bulky after the topical decongestant, then the author assumes the inferior turbinate bone itself is obstructing the airway. The patient will need a true submucosal resection of the inferior turbinate bone with the aid of a 3.5 microdebrider blade (Medtronic). This true submucosal resection will be described later in this article.

Submucous resection of inferior turbinate

After removing the cotton pledgets, use a 0° rigid nasoendoscope to examine both nasal cavities and assess the amount of inferior turbinate mucosal response to the oxymetazoline. If the turbinate hasn’t changed much in size and the airway is still obstructed, then a true submucous resection of the inferior turbinate is the method of choice. If this is being performed with a septoplasty or endoscopic sinus surgery, save the turbinate reduction as the last procedure.

Infiltrate 1% lidocaine with 1:100,000 epinephrine into both inferior turbinates. Concentrate on the medial, lateral, and inferior mucosa of the turbinate. Use a Boise elevator to medialize the inferior turbinate. Using a 3.5-mm microdebrider blade, remove the inferior and lateral mucosa. Pay attention to how much tissue is removed at the posterior portion of the turbinate. Too much removal could lead to postoperative hemorrhage secondary to the feeding sphenopalatine artery branches.

Use a 15 blade (on a long handle) to make an incision at the anterior head of the inferior turbinate. The goal is to separate the medial mucosa from the inferior turbinate bone. Using either the freer or knife, raise the medial mucosa in a subperiosteal plane the whole length of the inferior turbinate bone. If obstructive bleeding occurs, use the suction freer to help raise the flap.

Once the entire inferior turbinate bone is isolated, use curved, long Metzenbaum scissors to amputate the inferior turbinate as high as possible and then taper the height inferiorly. Retrieve the inferior turbinate bone with Takahashi forceps. Use a Freer or Boise elevator to lateralize the medial mucosa and to outfracture any remaining inferior turbinate bone. Bleeding should be minimal, and most trouble spots are controlled with topical decongestant on a pledget. Using a suction cautery is rare, and the use of suction cautery tends to increase postoperative eschar and crusting. Repeat the procedure on the opposite side, and the nasal airway should significantly improve.

SMR inferior turbinate reduction

Soft tissue reduction of the inferior turbinate

If marked improvement occurs following the oxymetazoline, then only reducing the soft tissue of the turbinate may be the answer. Infiltrate 1% lidocaine with 1:100,000 epinephrine into the inferior turbinate. Then, use the sharp tip of the 2.0 mm inferior turbinate blade to puncture the anterior head of the inferior turbinate. Once the blade is submucosal and against bone, elevate the mucosa off the inferior turbinate. Activate the blade to remove the tissue against the bone and then turn the blade so the active portion is removing the soft tissue. Ideally, you should use a 0° rigid nasoendoscope to assess your progress. You should see an improvement as the soft tissue is slowly removed "inside-out." Then, use a Freer or Boise elevator to outfracture (lateralize) the inferior turbinate. Repeat this procedure on the opposite side. Bleeding should be minimal.

A video demonstrating the previously mentioned techniques can be seen below.