Turbinectomy

As the primary controller of nasal airflow, the nasal turbinates, particularly the inferior turbinate, play an important role in normal nasal respiratory function. The mucosa of the turbinate is an essential tissue for proper respiratory function. Its roles include air humidification, air filtration, and the warming of inspired air. ^[1] Nasal obstruction due to enlarged inferior turbinates is a relatively common occurrence in otolaryngology, and when more conservative treatment fails (nasal steroids, allergic rhinitis treatment, etc), turbinate surgery may be indicated. Otolaryngologists use many different techniques to treat enlarged turbinates. ^[2]

Although the nasal mucosa of the turbinates swells as part of the nasal cycle, outside agents such as infection, inhalant allergens, airborne irritants, and mucosal hyperreactivity can exacerbate the physiological swelling, necessitating a need for intervention. ^[3] Either the osseous or mucosal portion of the turbinate may be hypertrophic. For example, patients who present with allergic rhinitis generally have a swelling of the mucosa, while patients with a severe septal deviation may present with a unilateral enlargement of the bony component of the turbinate. ^[4] Knowing which portion of the turbinate is restricting airflow helps the surgeon determine which surgical techniques to use.

Various surgical techniques are available to reduce the size of the inferior turbinate. This includes turbinectomy, turbinoplasty, extramucosal or submucosal electrocautery, radiofrequency ablation (RFA), laser-assisted resection or ablation, and cryosurgery. ^[5] Most surgeons’ goals are to preserve as much turbinate mucosa as possible while removing as much inferior turbinate bulk as possible. This allows normal turbinate mucosa physiology to continue.

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 (see the image below).

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.

Turbinectomy

Turbinectomy is a partial or complete resection of the inferior turbinate with or without the guidance of an endoscope. The microdebrider instrument is often used in this procedure in order to remove some of the soft tissue component, and the debrider can be used even in the more complex cases of bony hypertrophy. ^[6] The exposed raw mucosal edges and bone from this procedure may lead to nasal crusting with need for postoperative debridement. The mucosal edges may continue to bleed despite electrocautery control and nasal packing may be needed for hemostasis. Some evidence exists that turbinectomy may lead to a high incidence of empty nose syndrome. ^[7] However, the evidence is conflicting, and results seem to be quite operator dependent.

Turbinoplasty

Two main techniques fall under the category of turbinoplasty. In the outfracture technique, an instrument is used to laterally reposition the turbinate and increase the patency of the airway. In the submucous resection technique, an incision is made at the head of the turbinate. A microdebrider and blunt dissectors are then used to remove some of the turbinate tissue. Subsequently, the mucosa is reapproximated and is allowed to heal over a smaller turbinate bone. Perforation of the mucosal flap or poor approximation of the incision can result in crusts, synechiae, and bleeding. ^[8]

Studies comparing many different types of turbinate reduction have shown that after 6 years of follow up, submucosal resection showed the highest degree of nasal patency with restoration of mucociliary clearance and secretion of IgA. The study also showed that outfracturing of the inferior turbinate after the submucous resection of the turbinate improved the long-term results. ^[1]

In another interesting study, it was found that facial plastic surgeons who were trained in the general surgery—plastics residency format—tended to use the more traditional turbinate reduction techniques versus the newer, novel, more minimally invasive techniques. The most commonly used technique was inferior turbinate outfracturing. ^[9]

Radiofrequency Ablation

Radiofrequency ablation (RFA) is a very common thermal technique in which a thermal probe is physically inserted into the inferior turbinate and the delivered radioenergy removes some of the tissue. This technique has the advantage that it can be done in the office setting under local anesthesia and it has rare and minor complications. ^[10] Studies show that RFA has better outcomes than placebo surgery. Since the surgery is relatively noncomplex, it can be seen as an attractive option for people with minor inferior turbinate airway obstruction who are seeking a surgical option. ^[11] Patients tend to have recurrences with RFA, but since it is a clinic procedure, recurrences are easily treated in the clinic.

RFA creates an ionization of submucosal tissue that subsequently leads to a scar that reduces the bulk of the surrounding tissue. Although fibrotic tissue replaces the glands and venous plexuses, nasal mucociliary function remains preserved. ^[12] The mucosal surfaces should not be involved.

Septoturbinotomy

Septoturbinotomy is a procedure typically performed with rhinoplasty. It is a minimally invasive procedure designed to expand the nasal vault by outfracturing the inferior turbinates and concurrently centralizing the vomer. This is performed by inserting a long nasal speculum along the nasal floor. It is aggressively opened to audibly outfracture the inferior turbinate bone and push the deviated vomer centrally. Alternatively, a large clamp can be used by opening it in a reverse “nutcracker” fashion. This technique has fewer complications (epistaxis, synechiae, and crusting) than traditional turbinate methods. ^[13]

Summary

Inferior turbinate reduction for nasal obstructive symptoms caused by enlarged turbinates is a useful procedure. It is not a complex surgery and, depending on the patient’s needs, the procedure can be done in the clinic or operating room setting. Generally, turbinate reduction is a safe procedure with minimal morbidity issues. An otolaryngologist who knows several methods of turbinate reduction will be able to help most patients with significant nasal obstruction issues.

Despite the popularity of turbinate surgery, otolaryngologists do not have a uniform, standardized way to define turbinate hypertrophy or to select a patient for turbinate surgery. Additionally, no standardized way to select the type of turbinate surgery needed exists. It is still a clinical judgment based on the patient’s symptoms, the physical examination, and nasoendoscopy findings. In general, indications include the following:

• Subjective nasal congestion due to turbinate hypertrophy that has failed appropriate medical therapy

• Surgical access during sinonasal surgery

• It can be done in combination with other airway surgery such as endoscopic sinus surgery, septoplasty, and multilevel treatment for obstructive sleep apnea.

Patients who live in a dry or dusty environment may not be good candidates (relative contraindication). Decreased surface area from the loss of some inferior turbinate mucosa can possibly predispose patients to dry nasal mucosa. This may lead to crusting and obstruction issues.

Although radiofrequency ablation is a simple technique, evidence exists that the short-term relief is significant. Garzaro et al reported on a 2-year follow-up, noting that patients experienced continued improvement in olfaction, subjective and objective improvement in nasal congestion, and improvement in overall quality of life.

For the more complex turbinoplasty techniques, such as Gupta’s modification of Mabry’s partial turbinectomy, the long-term outcomes are favorable. With a follow-up time up to 40 months after surgery, Gupta et al report that 96% had airway improvement. Less than 25% reported that they didn’t need to use nasal steroids and oral decongestants anymore. ^[14]

When these 2 techniques are combined, evidence favors the microdebrider-assisted turbinoplasty versus the radiofrequency ablation group. Objective measures show decreased overall volume of the inferior turbinate. Patients note subjectively better improved nasal congestion compared to the RFA group. ^{[15, 16]}