Turbinectomy 

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

Overview

Background

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).

Lateral nasal wall anatomy and paranasal sinus ost Lateral nasal wall anatomy and paranasal sinus ostia.

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.

Indications

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.

Contraindications

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.

Outcomes

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]

 

Periprocedural Care

Equipment

See the list below:

  • Audiovisual tower

  • Endoscopic camera head

  • 0° rigid nasal endoscope

  • Endoscopic sheath: This helps guard the scope from any accidental trauma and helps give the rigid scope some weight. This added weight tends to help manual dexterity and provide instrument feedback during the case.

  • #8 Frazier tip suction

  • #15 blade

  • Takahashi forceps

  • Long Metzenbaum scissors

  • Suction cautery for troublesome bleeding

  • Boise elevator

  • Freer

  • Suction Freer

  • Microdebrider and handpiece (Medtronic Xomed StraightShot M4 Microdebrider, Integrated Power Console)

  • Tricut Blade 3.5 mm microdebrider blade (Medtronic)

  • 2.0 mm Inferior Turbinate Blade (Medtronic)

Patient Preparation

Anesthesia

Under most circumstances, the author performs the following turbinate reduction procedures using general anesthesia.

Using a headlight and a nasal speculum, examine the nasal airway taking note of the size of the inferior turbinates. Place 2 oxymetazoline pledgets (1/2 in by 3 in) in both nasal cavities (4 pledgets needed).

Positioning

The room is set up like a sinus endoscopy case. Because the author is a right-handed surgeon, he has the AV tower and monitor across from him on the patient’s left-hand side, and he will stand on the patient’s right. The patient is supine, and the anesthesiologist tapes the endotracheal tube to the left. The author tucks the patient’s right arm only, and the anesthesiologist will have access to the left arm. The author prefers that the anesthesiologist place the blood pressure on the patient’s left arm so the cuff doesn’t repeatedly inflate in the author’s way during the case. The patient is prepped and draped in the standard fashion for endoscopic sinus surgery.

Complications

Complications may include the following:

  • Postoperative epistaxis

  • Pain

  • Recurrence

  • Crusting

  • Foul odor

  • Synechia

  • Epiphora from nasolacrimal duct injury

  • Atrophic rhinitis or empty nose syndrome: This is typically seen in total or radical turbinectomy.

 

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.

 

Medication

Medication Summary

See the list below:

  • Oxymetazoline (nasal spray)

  • 1% lidocaine with 1:100,000 epinephrine