Lasers in Surgery and Medicine 39:324–331 (2007)

Comparison of Long Term Results After Ho:YAG and DiodeLaser Treatment of Hyperplastic Inferior Nasal Turbinates

Ronald Sroka, PhD,1* Philip Janda, MD,2 Tina Killian, DMD,2 Francis Vaz, FRCS,3

Christian S. Betz, MD,2 and Andreas Leunig, MD2

1Laser-Research Laboratory at the LIFE-Center, Ludwig-Maximilians University, 81377 Munich, Germany2Department of Oto-Rhino-Laryngology/Head & Neck Surgery, Ludwig-Maximilians University,81377 Munich, Germany3Department of Head and Neck Oncology, University College London Hospital, London NW1 2PG, United Kingdom

Background and Objective: Various laser systems havebeen used to reduce the volume of hyperplastic inferiornasal turbinates during the last 25 years. Although thereare many studies reporting the clinical results immediatelyafter laser treatment, there are only a few describing long-term results. Therefore, a clinical study was performed toassess and to compare the long-term outcome of bothendonasal Ho:YAG and endonasal diode laser-assistedturbinate surgery.Study Design/Materials and Methods: In the firsttreatment group, a total of 80 patients (allergic rhinitis(46%) and vasomotor rhinitis (54%)) suffering from nasalobstruction due to hyperplastic inferior nasal turbinateswere treated by a pulsed Ho:YAG laser emitting light at awavelength of l¼ 2,100 nm (pulse energy: 0.8–1.2 J/pulse,repetition rate: 4–8 Hz) under local anesthesia. In thesecond group, an additional 113 patients (allergic rhinitis(52%) and vasomotor rhinitis (48%)) were treated by meansof a continuous wave GaAlAs-diode laser emitting light at awavelength of l¼ 940 nm (power: 8–10 W). The treatmenttime was 3–10 minutes per turbinate and the nasal cavitieswere left unpacked following the procedure. The studyconcerning long-term effects was conducted using astandardized questionnaire, allergy test, and rhinomano-metry within a follow-up period of 6 month and after3 years. All patients were refractory to conservativemedical treatment prior to laser treatment.Results: Three years after laser treatment, a subjectiveimprovement of nasal airflow had been described by thepatients in 67.5% after Ho:YAG- and in 74.4% after diodelaser treatment. Rhinomanometry revealed a significantimprovement of the nasal airflow at both 6 months and3 years after the laser treatment as compared to thepreoperative data. Side effects like nasal dryness and painwere rare (<5%) and occurred only during the first weeksafter the intervention. After diode laser treatment, patientsshowed nasal obstruction due to postoperative edema andnasal crusting during the first 3–4 weeks, whereas patientsfrom the Ho:YAG laser group described these symptomsonly for a period of 1–2 weeks.Conclusion: Both Ho:YAG- and diode laser treatment,which are performed as an outpatient procedure under

local anesthesia, show promising long-term results. It hastherefore, developed to become a time and cost-effectivetreatment modality in endonasal laser surgery at ourinstitution. While short-term differences concerning thehealing process after Ho:YAG- compared to diode-lasertreatment could be ascertained according to the subjectiveand objective evaluation, no significant long-term differ-ences between the two investigated groups could beobserved. Lasers Surg. Med. 39:324–331, 2007.� 2007 Wiley-Liss, Inc.

Key words: allergic rhinitis; diode laser; Ho:YAG laser;inferior nasal turbinates; nasal obstruction; vasomotorrhinitis; long-term follow up

INTRODUCTION

Nasal obstruction due to hyperplastic inferior nasalturbinates is a frequently observed, rhinological symptomwhich has a negative influence on the quality of life ofthe patients concerned. An increase of incidence of thedescribed symptoms indicates a need for a treatmentthat terminates the complaints. Conservative therapy isrestricted to decongestion using topically applied a1-adrenergic substances, antihistamines, topical and sys-temic steroids, allergen avoidance, and hyposensitizationas specific immunotherapy [1]. Since these treatmentmodalities only have short-term effects [2], surgical inter-ventions become necessary in many cases.

Many different surgical procedures have been describedfor volume reduction of hyperplastic inferior nasal turbi-nates [1–10]. Because most of these techniques areassociated with a distinct risk of bleeding, pain, uncon-trolled damage of the mucosa, and atrophic rhinitis, there isstill the need for a less traumatic treatment. Laser surgery

*Correspondence to: Ronald Sroka, PhD, LIFE-Center ofUniversity Munich, Laser Research Laboratory, Klinikum Grob-hadern, Marchioninistr.23, 81377 Munich, Germany.E-mail: ronald.sroka@med.uni-muenchen.de

Accepted 5 December 2006Published online 15 February 2007 in Wiley InterScience(www.interscience.wiley.com).DOI 10.1002/lsm.20479

� 2007 Wiley-Liss, Inc.

offers the advantage of limited tissue trauma, less bleedingand a high patient acceptance under outpatient conditions.For a period of about 25 years, different laser types havebeen used for the treatment of hyperplastic inferior nasalturbinates [11–20]. The fundamental difference betweenthese laser systems is the wavelength of the emitted light,which then provokes different interactions in between laserlight and tissue.

The CO2 laser light (l¼ 10,600 nm) is highly absorbed bywater and makes the CO2 laser an ideal tool for cutting andsuperficial vaporization of tissue. The Nd:YAG laser, on theother hand, emits light at l¼ 1,064 nm, penetrates deeplyinto the tissue and induces large coagulation areas in non-contact mode, while contact application also generateseffective cutting and vaporizing qualities. Laser light of thePotassium-Titanyl-Phosphate laser (KTP), emitting atl¼ 532 nm, and the Argon-ion laser (l¼ 488/514 nm) areabsorbed by endogenous chromophores as for examplehemoglobin, and therefore are often used in the treatmentof vascular malformations (e.g., Osler–Weber–Rendudisease). The pulsed, solid state Ho:YAG laser, emittinglight at l¼ 2,100 nm, enables good cutting capabilities ofboth bone and soft tissue in combination with creating agood hemostasis. The diode laser emitting at l¼ 940 nmlight is mainly absorbed by water and blood and thereforeprovides excellent coagulation capabilities in ‘‘non-contact’’mode, which are slightly less pronounced than for theNd:YAG laser.

Due to their favorable capabilities concerning light tissueinteractions, the Ho:YAG and the diode laser systems werechosen in the presented clinical trial to examine and tocompare the clinical effects exerted by these different laserswith respect to postoperative symptoms as well as in a3-year long-term follow-up. It is known that after surgicaltreatment of the turbinates, physiological rhinosinusoidalmechanisms need at least 2 years to be restored, andstarting from the third year of follow-up, nasal patency mayagain begin to worsen [21–23]. For this reason, patientsthat had a surgical volume reduction of hypertrophiedinferior turbinates need to be followed up for at least 3 yearsto show reliable results. With respect to this and in additionto the fact, that there are only few studies describing long-term results after endonasal laser interventions, a follow-up period of 6 month and of 3 years was chosen to comparethe outcome of the treatment performed by these twodifferent lasers.

MATERIALS AND METHODS

From August 1997 to July 2004, 657 patients sufferingfrom nasal obstruction due to hyperplastic inferior nasalturbinates were treated by means of a laser intervention atthe Department of Oto-Rhino-Laryngology/Head & NeckSurgery (Head: Prof. Dr. A. Berghaus) of the Ludwig-Maximilians University in Munich, F.R.G. The lasertreatments were either performed by c.w. (continuouswave) diode laser (Dornier Medilas D, Germering, Munich,F.R.G.), emitting light at a wavelength of l¼ 940 nm, or apulsed Ho:YAG laser (Dornier Medilas H, Germering,Munich, F.R.G.), emitting light at a wavelength of

l¼ 2,100 nm. Owing to logistical organization about onethird (n¼ 193) of all patients could be followed up in aretrospective, non-randomized comparative study, and 90of these patients could be objectively evaluated by rhino-manometry within a follow-up period of 3 years on average.All patients included into the survey were refractory topreoperative medical treatment. Criteria for inclusion intothe trial were nasal obstruction due to hyperplastic inferiornasal turbinates with positive correlation to rhinomano-metric test results and no further interventions within thepreceding 3 years. During follow-up, those patients suffer-ing from allergic rhinitis are allowed to continue theirsymptomatic treatment in the same manner either orally ortopically as prior to laser intervention. Patients receiving ahyposensibilization treatment or changing their sympto-matic treatment were excluded. Patients with evidenceof a clinically significant deviated nasal septum, acute orchronic rhinosinusitis, and nasal polyps were excluded.

Prior to laser treatment, topical anesthetics were appliedfor about 10–15 minutes, using cotton pads imbibed with amixture of 4% Tetracaine and 0.5% Xylometazolin solution(50:50). For documentation purposes, a rigid rhinoscope(08-optic, OD 4 mm, Karl Storz, Tuttlingen, F.R.G.) wascoupled with photo- and video-documentation devices.The application of the laser light was performed in ‘‘non-contact’’ mode using a soft-bending, plastic-clad, silica fiber(400 mm core diameter) placed into a special designed laserfiber guidance system [21] (Karl Storz GmbH, Tuttlingen,F.R.G.). The laser parameters were set to a pulse energy of0.8–1.2 J/pulse at a repetition rate of 4 to 8 Hz in the caseof the Ho:YAG laser, and to a power of 8–10 W in the case ofthe c.w. emitting diode laser system. On average, 3–4 laserlight applications were performed by guiding the fiber fromthe posterior to the anterior part of the inferior turbinate inaddition to some single laser spots onto the head of theturbinate. Following laser treatment, the duration ofsurgery, laser power settings, and total energy appliedwere recorded. Postoperatively, antibiotic ointment wasapplied to both nasal cavities and the patients were put on aprotocol of saline irrigations, nasal ointments and (asrequired) decongestive nose drop for a 4 weeks term.Clinical examination, photo- and video-documentationwere performed before as well as 6-months and 3 yearsafter laser treatment.

Prior to as well as 6 months and 3 years after lasertreatment, the nasal airflow was quantified in 90 patients(broken down by etiology: nallergic¼ 44, nnon-allergic¼ 46;broken down by laser system used: nHo:YAG¼ 51,nGaAlAs¼ 39) by active anterior rhinomanometry (G. Hei-nemann, Medizintechnik, Hamburg, F.R.G.) prior to and10–15 minutes after nasal decongestion with 1% Pheny-lephrine-solution under standardized conditions [24,25] ata pressure of 150 Pa. The individual relative changebetween the pre- and postoperative nasal airflow wasdetermined. A difference of � 15% in the nasal airflow ofthe preoperatively measured value as compared to thepostoperative value was neither taken into account forimprovement nor worsening of the nasal airflow in rhino-manometric measurements, because there is a coefficient of

HO:YAG AND DIODE LASER TREATMENT OF NASAL TURBINATES 325

variation of about 15% in rhinomanometry [26,27]. Toseparate the results of allergic from vasomotor rhinitispatients, every patient underwent an allergy test, usingboth, the Paper Radio Immuno Sorbent Test (PRIST) andthe Radio Allergo Sorbent Test (RAST).

Moreover, a customized questionnaire was sent out andanswered by 193 patients (nHo:YAG¼ 80,nGaAlAs¼ 113). Thequestionnaire contained subjective changes in nasalobstruction, anterior and posterior rhinorrhea, sneezing,itching of nose and eyes, olfactory disorders, headaches,and overall quality of life, general condition and if thepatients would repeat the procedure if necessary and wouldrecommend the laser therapy to others, respectively.

Statistical analyses of the objective parameters wereperformed using non-parametric methods including chi-squared correction, Friedmann’s test for more than tworelated variables and Wilcoxon sign rank test for compar-ison between two related variables (SPSS 8.0 for WindowsNT [28]). As the study group did not conform to a standarddistribution of symptom scores and airflow measurements,qualitative data were displayed in box plots showing therange of values within the 10 and 90 percentiles. Thecomparison between the measured values was regarded tobe significant for P�0.05 in the Wilcoxon test.

RESULTS

No immediate complications such as major bleedingrelated to the treatment was observed after either theHo:YAG- or diode laser treatment. The operation para-meters as well as minor complications are listed in Table 1.Whilst the individual operation parameters could differsuch as operation time and the energy applied perturbinate, it appears that Ho:YAG laser treatment wasperformed faster and with less energy in comparison todiode laser treatment. The initial nasal obstruction follow-ing laser treatment was directly correlated to the extent of

nasal crusting and lasted for a period of approximateley2 weeks in the case of Ho:YAG-treated patients incomparison to 3–4 weeks after diode laser treatment. TheFigure 1a shows the endoscopic finding of a hyperplasticinferior turbinate with a narrow nasal cavity prior to lasertreatment. The response 3 years later, given in Figure 1(right), demonstrates a widened nasal lumen and a reducedinferior nasal turbinate due to laser induced tissuereduction.

After a follow-up period of 3 years, 67.5% (54/80) of thepatients described a subjective improvement of the nasalbreathing after Ho:YAG and 74.4% (84/113) after diodelaser treatment. According to the allergy testing, 58.8% ofthe patients from the non-allergic cohort and 85% of thepatients suffering from allergic rhinitis had a subjectiveimprovement of nasal breathing 3 years after laser surgery

TABLE 1. Comparison of Ho:YAG and Diode Laser

Treatment Parameters, Subjective Appraisement, and

Initial Side Effects

Ho:YAG-laser

GaAlAs-diode

laser

Surgical parameters

Mean operation time 5 minutes 6 minutes

Range 3–8 minutes 4–10 minutes

Mean energy applied

per turbinate

287 J 423 J

Range 70 J–670 J 90 J–1,350 J

Patients treated n¼ 80 n¼ 113

Subjective evaluation

Subjective improvement

after 3 years

67.5% 74.4%

Initial side effects

Minor bleeding 5% 3%

Nasal dryness 8% 3%

Pain 4% 5%

Fig. 1. Photographs (taken without any nasal decongestion) of

a hyperplastic inferior turbinate of the left nasal cavity prior to

(a) and 3 years (b) after pulsed Ho:YAG laser treatment

(individual laser parameter: pulse-energy 1 J/pulse, repetition

rate 6 Hz, total applied energy 470 J).

326 SROKA ET AL.

independent of the laser used. As seen in Table 2,the standardized questionnaire revealed that 64% ofthe patients described an improvement of the general lifequality after laser surgery. Sixty-six percent of all patientswould accept a repetition of the treatment if necessary and67% would recommend the laser procedure to other people.Concerning the postoperative period, 90% of the patientsfelt in good general condition after the laser surgery.

Statistical analysis revealed that there were significantincreases in nasal airflow at 6 months (Wilcoxon test:PHo:YAG< 0.001; PGaAlAs< 0.001) and 3 years (Wilcoxontest:PHo:YAG< 0.001;PGaAlAs< 0.001) following laser treat-ment with both GaAlAs diode- and Ho:YAG laser whencompared with their pre-operative values (Fig. 2a,b).Moreover, it could be shown that nasal airflow significantlydecreases from 6 months to 3 years following treatmentin case of the GaAlAs diode laser (Wilcoxon test:PGaAlAs< 0.0001), whereas no significant decrease of thenasal airflow could be determined for the Ho:YAG lasersystem (PHo:YAG< 0.059) within the same time period.

On further statistical analysis between non-allergicpatients (n¼ 46) and patients suffering from allergies(n¼ 44) as shown in Figure 3a,b, the results show asignificant improvement of the nasal airflow in rhinoma-nometry after 6 months as well as after 3 years using bothkinds of laser systems (Wilcoxon test: PHo:YAG< 0.001;PGaAlAs< 0.001) with regard to pre OP-values. Interest-ingly, 3 years after laser surgery, the values of the patientswith an allergy revealed a significant decrease of the nasalairflow when compared to the rhinomanometric measure-ments 6 months after laser surgery (Wilcoxon test:Pallergic< 0.012). In comparison, the non-allergic patientscohort showed no significant decrease of the measuredairflow at 3 years after laser therapy compared to theresults at 6 months.

DISCUSSION

Several surgical procedures including conchotomy,inferior turbinoplasty, partial and total turbinectomy,lateral outfracture, electrocautery, cryotherapy, chemicalcauterization, vidian neurectomy, and laser therapy havebeen described for the reduction of hyperplastic inferiornasal turbinates [1–20]. The application of a series of

different laser systems such as CO2 [12–14,29–31],Nd:YAG [15,16], KTP [17,32,33], Argon-ion [18], andHo:YAG laser [19,20,34,35] have been discussed success-fully in various clinical trials.

Lippert and Werner [12] used the CO2 laser to applysingle laser spots (power 1–4 W, fluence rate 2,038 W/cm2)to the turbinates. As a result, 82.1% of the patients had animprovement at 1 year and 80.4% of the patients stillshowed improvement at 2 years after the laser treatment,which is in agreement with Sandhu et al. [31]. Kawamuraet al. [13] and Fukutake et al. [14] described the subjectiveresults of CO2 laser surgery for allergic rhinitis. Both used adefocused laser beam at a power of 20 W. Kawamura et al.[13] demonstrated a success rate of 85% 2 years after lasertreatment, whereas Fukutake et al. [14] had a subjectiveimprovement in 77% of their patients after 1 year.

Olthoff et al. [16] reported a prospective study on117 patients, using the Nd:YAG laser in contact mode(power 8 W, energy applied per turbinate 350–400 J) for the

TABLE 2. Subjective Evaluation in Detail at 3 Years

Post Laser Intervention

Question Yes No No comment

Do you feel an improvement

of your general life quality?

64% 33% 3%

Would you repeat the

procedure if necessary?

66% 28% 6%

Would you recommend the

procedure to others?

68% 25% 7%

Did you feel in good general

condition after laser

surgery?

90% 8% 2%

Fig. 2. a: Results of statistical analysis of measurements using

rhinomanometry after GaAlAs-diode-laser treatment (n¼ 39).

b: Results of statistical analysis of measurements in rhinoma-

nometry after Ho:YAG-laser treatment (n¼ 51). In both cases,

the nasal airflow of the nasal cavity was measured at a

pressure of 150 Pa pre-operatively, 6 months and 3 year after

laser treatment. Box plots show the range of values within the

10, 25, 50 (median), 75, and 90 percentiles.

HO:YAG AND DIODE LASER TREATMENT OF NASAL TURBINATES 327

treatment of allergic and vasomotor rhinitis with animprovement of nasal breathing in 80% of the cases 1 yearafter the laser procedure. In contrast to Olthoff et al. [16],Lippert and Werner [12] applied the Nd:YAG laser light(power 5–10 W, fluence rate 1,770–3,540 W/cm2) in non-contact mode, which resulted in a 72.5% success rate 1 yearafter laser surgery.

Janda et al. [36] showed that diode laser treatment(l¼ 940 nm) of hyperplastic inferior nasal turbinatesresulted in a subjective improvement of nasal airflow in76% of patients and did not correlate with significantvariations in the mucociliary function test. In accordancewith Newman and Anand [37], it was concluded that diodelaser treatment (l¼ 980 nm) is ideally suited for intranasaluse resulting in a controlled coagulation and ablation of thesoft tissue in a short treatment times with excellent patientacceptance.

Levine et al. [17] treated 63 patients using the KTP laser(power 5–8 W), of which 12 were followed-up for 1 year. As aresult, 80% of the patients showed an improvement of thenasal airway passage, less nasal congestion, and lessdischarge. While KTP laser intervention was shown toeffectively reduce the symptoms of nasal obstruction with-out any significant complications [32], Wang et al. [33]achieved an improvement in 87% after a follow-up of 2 yearsafter KTP-laser treatment.

Similar results have been observed by Lenz [18] in astudy using the Argon-ion laser (power 8 W) in 411 patientssuffering from vasomotor rhinitis. One to five years afterlaser therapy, 80% of the patients described a subjectiveimprovement of nasal airflow.

Finally, four studies [19,20,34,35] have been performedconcerning the effects of the Ho:YAG laser on the reductionof hyperplastic inferior turbinates in vasomotor andallergic rhinitis. While Leunig et al. [20,35] (repetition rate4–8 Hz; pulse energy 0.8–1.2 J/pulse) observed a subjectiveimprovement of nasal breathing in 77% of the patients1 year after laser treatment, Serrano et al. [19] (repetitionrate 5 Hz; pulse energy 0.8 J/pulse) noted an improvementin only 52.2% of their patients 16 months after lasertherapy. Although the Ho:YAG laser treatment could beperformed with only low morbidity, the poor long-termbenefit of about 50% of the patients was thought to berelated to limited tissue damage [34].

Both, Argon-ion (l¼ 488/514 nm) and KTP laser(l¼ 532 nm) emit light suitable to induce hemostasis (e.g.,Osler-Weber-Rendu Disease) and to treat strong vascularstructures (e.g., hemangiomas, naevi flammei) [17,18,32].This was because of targeting to the specific absorptioncharacteristics of hemoglobin, while all other lasers usedare interacting more on the basis of non-specific waterabsorption. In the present study, the diode laser was usedbecause of its deep coagulation properties includingnecrosis of the venous plexus of the nasal turbinate[38,39]. Similar effects were described when the Nd:YAGlaser was used [15,16]. The Ho:YAG laser represents a goodcompromise of ablation and coagulation depending on theparameters used [38–40].

Patients treated by means of the diode laser showed amoderate to severe nasal obstruction, crusting, and nasalsecretion within the first 4 weeks after laser treatment.Afterwards, nasal crusting subsided, the turbinate re-epithelialized, and a subjective relief of the nasal obstruc-tion became apparent. This might be explained by the factthat coagulated tissue swells up immediately after surgeryand is desquamated 4 weeks later followed by scarformation. In contrast, laser systems with better ablationbut less coagulation properties, like the Ho:YAG laser,showed the same symptoms but for only 1–2 weeks [20,35].The mucociliary function test revealed no significantchange between the pre-operative and the post-operativenasal clearance, which proves that the diode as well as theHo:YAG laser treatment seems to preserve the overallfunction of the ciliary cells of the nasal turbinates [35].Similarly, no changes in mucociliary transport times werefound after CO2-laser intervention [30].

Fig. 3. a: Results of statistical analysis of measurements in

rhinomanometry of patients suffering from allergic rhinitis

after laser treatment (n¼ 44). b: Results of statistical analysis

of measurements in rhinomanometry of patients suffering

from vasomotor rhinitis after laser treatment (n¼ 46). In both

cases the nasal airflow of the nasal cavity was measured at a

pressure of 150 Pa pre-operatively, 6 months and 3 year after

laser treatment. Box plots show the range of values within the

10, 25, 50 (median), 75, and 90 percentiles.

328 SROKA ET AL.

Acoustic rhinometry measurements have revealed thatlaser treatment induces a significant increase of the volumeof the nasal cavity for the length of the inferior turbinateafter the laser procedure in comparison to the pre-operativevalues [40–44]. It has also been objectively proven byrhinomanometry that laser treatment leads to a volumereduction of the cavernous body of the turbinate[30,31,35,36,45,46]. As a clinically significant nasalobstruction is defined by a total nasal resistance of largerthan 1 cmH2O/(l � second) in rhinomanometry [43] and noneof the treated patients in this study achieved a smallerresistance than 1 cmH2O/(l � second), all of the observedcases are by definition still suffering from some degree ofnasal obstruction both at 6 months and 3 years after thelaser treatment. It may therefore be deduced from theresults obtained in this study that laser treatmentsignificantly reduces the symptoms of nasal obstruction,but does not lead to a complete resolution of the condition.Nevertheless, statistical analysis showed a significantincrease of the nasal airflow compared to pre-operativemeasurements at 6 months and 3 year after lasersurgery, respectively. Individual improvements in nasalair flow of more than 200% in rhinomanometry wereevident, but the overall improvement was estimated to beabout 50%.

Allergy testing showed that the long-term results of thelaser treatment of the nasal turbinates differed for patientssuffering from allergic rhinitis as opposed to vasomotorrhinitis. About 90% of the allergic patients could further-more not report on any changes of their additional allergicsymptoms like nasal discharge or itching, indicating thatthe reason of the allergic reaction was not eliminated. Asthe patients go back to live in their familiar environmentincluding their individually relevant allergens, this mayinduce a recurrent hyperplasia of the nasal turbinatesresulting in a renewed, persistant allergic inflammation ofthe nasal mucosa [27]. Nevertheless, patients sufferingfrom nasal allergies still described an overall subjectiveimprovement of nasal breathing during the follow-up timeof 3 years after laser treatment. This suggests that laserintervention in cases of allergic rhinitis shows a lesspronounced and shorter lasting effect than in vasomotorrhinitis, but it still concurs with a significant relief of thesymptoms of nasal obstruction. With respect to immunolo-gical responses, Mori et al. [47] demonstrated a decrease inthe allergic immune reaction after KTP-laser therapy,while Jovanovic [27] could not prove a reduction of allergicmediators (e.g., histamin, bradykinin). Dividing the aller-gic group into seasonal and perennial allergic patients,Takeno et al. [46] showed that laser therapy can besuccessfully applied to patients suffering from seasonalexacerbations by airborne pollen. Even though the objec-tive measurements in long-term follow-up show a reducedimprovement when compared to non-allergic patients,most of the allergic patients would still recommend thelaser treatment to relatives and friends [31]. Overall, thepresented study shows that patients suffering from allergicrhinitis are more sensitive and more attentive to changeswithin the nasal cavity. Subjective appraisement after

laser intervention referred to better well-being and animproved quality of life.

Surgical procedures should be pursued once the cause ofturbinate hyperplasia has been determined and useful non-surgical management (i.e., decongestants, antihistamines,intranasal corticosteroids, allergen avoidance) of nasalobstruction has failed. Various non-surgical and surgicaltreatment possibilities have been discussed in the past.Simmons [48] and Mabry [49] reported about good resultsin submucosal injection of corticosteroids in more than10,000 cases. However, the success of this treatment lastsonly about a month. Conchotomy, inferior turbinoplasty,lateral outfracture, partial and total turbinectomy hold theadvantage of directly removing hyperplastic parts of theturbinates, leading to a reduction of the obstructive tissue.A main disadvantage of this procedure is the considerablerisk of intra- and post-operative hemorrhage and thenecessity of nasal packing for a variable duration. Inaddition, prolonged crusting, exposure of bone, osteitis-induced granulation tissue, foul-smelling discharge, andsevere post-operative pain were observed. It is obvious thattotal turbinectomy produces an increased airflow, but atthe same time, it leads to ciliary destruction, atrophy of themucous membrane and chronic nasal infections with areduction of the humidifying capabilities of the nasalmucosa. Through his investigation in the use of electro-cautery, Jones et al. [8] revealed that only 39% of thepatients had an improvement of nasal airflow 15 monthsafter the treatment. Moreover, uncontrolled tissue damagewith considerable edema was described. Cryotherapy isalso of minor effect and requires revision surgery after ashort time [3–6]. Vidian neurectomy and cauterizationmight induce serious complications like blindness andanosmia and are therefore obsolete [9,10].

The present 3-year-long-term follow-up study includingtwo different laser systems indicates the usefulness of thelaser for intranasal reductive surgery of the turbinates.Although the interaction of laser light and tissue of the twolasers, either diode, or Ho:YAG laser, used scientificallydiffers just like the short-term outcome, the long-termoutcome is independent on the laser system used fortreatment. In cases of a rapid recurrence, a repeated lasertreatment is possible. In non-contact mode, it provides anexcellent coagulation of soft tissue, a controllable perfor-mance and good hemostasis in a mean operation time of lessthan 10 minutes. Laser treatment of nasal obstruction dueto hyperplastic inferior nasal turbinates can be performedas a minimally invasive procedure with satisfactoryresults. Although endonasal laser intervention by meansof the CO2, Nd:YAG, KTP, Argon-ion- or Ho:YAG laser arein clinical use, the diode laser is an attractive alternativeand ideally suited for endonasal surgery due to goodcoagulation properties. Although the purchase of a suitablelaser system imposes a significant financial burden, thisintervention seems to become highly cost-effective in thelong run as the procedure can be performed by a single headand neck surgeon under local anesthesia on an outpatientbasis without assistance, and nasal packing or tampona-des are not required. Furthermore, the portability and

HO:YAG AND DIODE LASER TREATMENT OF NASAL TURBINATES 329

functional diversity opens opportunities to also use thelaser system for other interventions or even share it withother medical specialites. The advantage of a bloodlesstherapy in an outpatient setting with high patientacceptance and satisfactory results as compared to severalsurgical techniques, which may cause bleeding, requirenasal packing, and hospitalization favors the laser surgery.

CONCLUSION

The treatment of hyperplastic inferior nasal turbinatesdue to chronic allergic and vasomotor rhinitis by means ofminimally invasive, endonasal laser surgery is a successfulalternative therapeutic intervention. In addition, the long-term results of success are evident when compared toconventional therapeutic procedures. The comparison ofthe outcome of two different laser systems in a 3-yearfollow-up shows that the initial response (up to 4 weeks)depends on the laser used (diode or Ho:YAG), while theshort-term (6 month) as well as the long-term (3 year)follow-up shows similarly significant improvements of thenasal airflow and comparable outcome independent to thelaser system used. Furthermore, this kind of laser inter-vention showed similar results to conventional surgicaltechniques while clinically, this minimally invasive lasertreatment concept can be performed as a cost effective,outpatient procedure under local anesthesia within a shortoperation time and with high patient acceptance.

ACKNOWLEDGMENTS

The skilful help of H. Forster, H. Stepp, E. Thielke, T.Pongratz, S. Stocker, U. Serini and E. Boehl is gratefullyacknowledged.

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