Medical Report Of :

Outcomes of Powered-Assisted Endoscopic Inferior Turbinoplasty

By:

Dr. Shalan Mufleh Darak HadedM.B.Ch.B

Al-Shaheed Gazi Al-Hariri hospital

for surgical specialities in the medical city

Baghdad 2014

Abstract

Aim of study: evaluation the outcomes of powered-assisted endoscopic inferior turbinoplasty in relieving the nasal obstruction.

Methods:study included 25 patients complaining from persistent nasal obstruction of more than 6 months despite of medical treatment for about 3 months. A powered-assisted endoscopic inferior turbinoplasty was done for each patient and the patients were followed for the 1st week, 1st month and 3rd month post-operatively.

Results:Preoperatively, nasal obstruction was 12% moderate and 88% severe while postoperative 3rd month 80% had no nasal obstruction and 20% had still mild obstruction. In other hand, the endoscopic grading of inferior turbinate was 76% grade III and 24% grade II in preoperative evaluation, then it became 88% grade I and 12% grade II in postoperative 3rd month. Therefore, there is significant changes in both nasal obstruction and turbinate size(p value=<0.05).

24% of patients developed mucosal tear during surgery without mucosal loss, 8% developed mild bleeding during removal of the packs and it needed only digital pressure to stop, 8% of patients developed crust formation during the 1st month postoperatively, then after instructing the patients to use nasal saline wash along with antibiotics for 2weeks, the crust disappeared.

Conclusion:outcomes of powered-assisted endoscopic inferior turbinoplasty were significant regarding relieving the nasal obstruction with few postoperative complications.

Introduction:

The inferior turbinates serve several important functions,including warming, humidifying and cleaning the inspired air.However, they are also the mainstructures contributing to chronic nasal obstruction.Several surgical techniques have been used to reducethe turbinate(33), however, no technique is perfect and each is associated with known short- andlong-term complications such as post-operative bleeding,crusting, foul odour, pain, hyposmia andsynechiae.

With the introduction of microdebriders to rhinosurgery by Setcliff and Parsons, many surgeons began toperform submucosal resection during inferior turbinoplasty,utilizing the advantages of the powered system.(37)

This technique has been reported to be safe method of achieving turbinate size reduction with minimal morbidity.

Patients and Methods:

This prospective study conducted in Al-Shaheed Gazi Al-Hariri hospital for surgical specialities in the medical city/ Baghdad from October 2012 to October 2013. The study included 25 patients complaining from persistent nasal obstruction of more than 6 months despite of medical treatment which consists of: intranasal steroid (budesonide nasal spray 64 microg 2puffs bid for 3months), antihistamine (loratidine tab.10mg once at night for 3months) and intranasal decongestant(oxymetazoline nasal drops for first 5days) .

Inclusion criteria:

1. Persistent nasal obstruction due to inferior turbinate mucosal hypertrophy , unilateral or bilateral , with or without septal deviation.

2. Failure of medical treatment for 3 months.3. Age >18 years old.

Exclusion criteria:

1. Inferior turbinate bony hypertrophy.2. Patients with nasal polyposis, tumors and granulomatous diseases.

All patients were evaluated by full clinical assessment, starting from taking full history about the nasal obstruction (onset, duration, severity, site) with associated nasal symptoms, along with past medical and past surgical history.

Each patient used a 4-points visual analogue scale (VAS) to grade his nasal obstruction separately preoperatively (day 0), at 1st week, 1st month and 3rd month after surgery. For example, score of 0 represented no nasal obstruction, a score of 1 represented mild obstruction(causing no disturbance in patient's daily life), a score of 2 represented moderate obstruction(forcing the patient to breath through his mouth), while a score of 3 represented severe obstruction(causing sleep disturbances and decrease in voice quality) .

After that complete nasal examination was done including nasal patency test (cold spatula test ), Cottle's maneuver, anterior rhinoscopy and nasal rigid endoscopy before and after nasal decongestant to exclude bony inferior turbinate hypertrophy.

Next, we evaluate each patient's nasal patency while we perform a modified Cottle maneuver that involves two different nasal manipulations : elevation of lower lateral cartilage and upper lateral cartilage using ear probe and evaluate the patency on VAS, then applying nasal decongestant drops(oxymetazoline 1%) and repeat all examination and evaluation again. Only these patients that had relief of their nasal obstruction after applying decongestant were included and will get benefit from turbinoplasty.

We graded the inferior turbinate from I to III, as Grade (I) was defined as mild enlargement with no obvious obstruction, Grade (III) was complete occlusion of the nasal cavity. The turbinates in between were graded as Grade (II).

In patients with nasal septal deviation, we evaluate the side with compensatory turbinate hypertrophy with the same method and interestingly we noticed that most of our patients considered that side as the main side of obstruction compared to that with septal deviation.

All patients sent for routine preoperative investigations (CBP, ESR, bleeding profiles, viral screening) along with Computed tomography of nose and paranasal sinuses in axial and coronal views for assessment and planning surgery.

We divided the patients into two groups: group A consisted of 10 patients who had bilateral inferior turbinate hypertrophy and received endoscopic inferior turbinoplasty, and group B consisted of 15 patients who had septal deviation with contralateral inferior turbinate compensatory hypertrophy and received endoscopic inferior turbinoplasty along with septoplasty.

All patients were informed about the details ofthe procedure to achieve the ethical point of view and written consents were taken from all the patients.

Operative procedure:

Under general anesthesia using endotracheal intubation, with the patient lying in supine position with head elevated 15°, using Hopkins rod 0° endoscope, and applying local nasal packs soaked with Oxymetazoline 1% inserted in the nasal floor medial and anterior to head of inferior turbinate for 10 minutes. Then we precede the procedures in these steps:

1. Using endoscope, we did incision about half cm in the anterior head of the inferior turbinate using No.15 blade in vertical manner.

2. We made a submucosal pocket along the medial side of inferior turbinate through that incision using Freer's elevator.

3. A straight microdebrider blade (2.0 mm) incorporated with an elevator (Medtronic XomedInc, Jacksonville, Fla) was inserted through the incision into the pocket. Debridement of submucosal tissue from the inferior turbinate was performed, moving back and forth in a sweeping fashion with the blade positioned mediolaterally from the submucosal plane at a speed of up to 3000 rpm. Particular attention was paid to preserve the mucosal flap. Immediate shrinkage of the size of turbinate was observed. This done bilaterally for patients in group A, while only in the side of compensatory hypertrophy in patients in group B.

4. The incision was not closed, and merocel nasal packs were inserted. The procedure took about 10 to 15 minutes each side.

5. in group B, we did conventional septoplasty to them with insertion of bilateral silastic sheets.

Post-operative follow-up:

1. Merocel packs were removed 48 hours post-operatively.2. Patients were instructed to take antibiotics(amoxiclave 625mg 1*3

for 7 days) along with nasal saline wash and nasal decongestant(oxymetazoline drops 1% for 5days)and intranasal steroid(budesonide nasal spray 64 microgm 2puffs bid for one month).

3. Silastic sheets were removed after one week post-operatively.4. Patients were seen one week, one month and 3 months post-

operatively and all the evaluation methods ( VAS, endoscopic nasal examination) were done.

5. Complications of bleeding, mucosal tears, crusting or synechia were treated.

Results:

Age distribution:

The range of patient age is between 18 to 43 years with average is 25 years.

Table(1) age distribution

Age group(year) No. of patients Percent18-28 19 7629-38 5 2039-48 1 4

gender distribution:

in this study, we have 10 male patients and 15 female patients.

Table(2) gender distribution

Sex No. of patients Percent Male 10 40Female 15 60Total 25 100

Side of turbinate hypertrophy :

During pre-operative assessment, we have 15 patients (60%) that had unilateral turbinate hypertrophy while 10 patients (40%) that had bilateral turbinate hypertrophy.

Table(3) side of turbinate hypertrophy

Side of turbinate hypertrophy

No. of patients Percent

Unilateral 15 60Bilateral 10 40Total 25 100

Type of surgery:

We have 2groups according to the type of surgery, group A had bilateral turbinoplasty for 10 patients, and group B had unilateral turbinoplasty along with septoplasty for 15 patients.

Table(4) type of surgery

Type of surgery No. of patients PercentBilateral turbinoplasty

10 40

Unilateral turbinoplast with septoplasty

15 60

Total 25 100

Subjective evaluation of nasal obstruction:

Subjective symptom of nasal obstruction was evaluated on pre-operative day, and 1st week,1st month and 3rd month post-operatively using 4-point scale.

Table(5) subjective evaluation of nasal obstruction

Pre-operative day

1st week post-operatively

1st month post-operatively

3rd month post-operatively

0 no nasal obstruction

0 3(12%) 18(72%) 20(80%)

1 mild obstruction

0 15(60%) 7(28%) 5(20%)

2 moderate obstruction

3(12%) 7(28%) 0 0

3 severe obstruction

22(88%) 0 0 0

Endoscopic grading of inferior turbinate:

Accordingto Friedman et al(39), we graded the inferior turbinate into 3 grades : Grade (I) was defined as mild enlargement with no obvious obstruction, Grade (III) was complete occlusion of the nasal cavity. The turbinate in between was graded as gradeII. We did this grading using endoscopic examination in pre-op. day 0 , post-op. 1st week, 1st month and 3rd week.

Table(6) endoscopic grading of inferior turbinate

Grade Preop. 1st week postop.

1st month postop.

3rd month postop.

Grade I 0 21 22 22Grade II 6 4 3 3Grade III 19 0 0 0 Pearson Chi-Square=53.977; DF=6 ; P-Value= 0.0001 SN

Complications:

1-Mucosal tear:

Per-operatively, we observed that 6 of patients (24%) develop mucosal tear but without mucosal flap loss.

Table(7) mucosal tear

Mucosal tear No. of patient Percent Presence 6 24%Absence 19 76%

2-Bleeding:

Per-operatively, no one of our patients develops major bleeding that need further intervention, while post-operatively ( at time of pack removal/48 hours) there is mild bleeding reported in 2patients(8%), required only digital pressure to stop.

Table(8) bleeding post-operatively

Bleeding No. of patients Percent Presence 2 8%Absence 23 92%

3-Crust formation:

At the 1st month post-operatively, we observed crust formation in 2 patients (8%). We instruct them to use aggressive nasal saline wash along with antibiotics for 2weeks, the crust disappeared.

Table(9) crust formation

Crust formation 1st month Presence 2(8%)Absence 23(92%)

Discussion:

In this study, a total 25 patients were conducted in prospective study to evaluate the outcomes and complications of powered assisted endoscopic inferior turbinoplasty. The age of the patients were between 18 and 43 years while in study by Friedman.et al(26) the age was between 19 and 71 years, and study by Hegazy H. et al(42) the age was between 19 and 35 years. Our group age groups were cooperative and more precise in evaluating the sense of nasal obstruction.

The gender distribution in our study was 10 males(40%) and 15 female(60%) while in study of Friedman et al , the gender distribution was 78 males and 42 females. In study of Hegazy H. et al, the gender distribution was 22 males and 28 females.

As subjective evaluation in our study before surgery, there were 3(12%) patients that had moderate nasal obstruction, while 22(88%) patients had severe nasal obstruction. After surgery(3rd month post-operatively), a 20(80%) patients had no nasal obstruction, while 5(20%) patients still had mild nasal obstruction. In study of Friedman et al, a 83% of the patients were suffered from severe nasal obstruction, while 17% had moderate nasal obstruction before surgery. After surgery, 25%of the patients had mild nasal obstruction and 75%hadno nasal obstruction. In his study, Hegazy H. et al showed that 90% suffered from severe nasal obstruction and 10% had moderate nasal obstruction pre-operatively. But after surgery, 20% had mild nasal obstruction while 80% had no nasal obstruction.

As objective data in our study, we have 6(24%) patients had grade II inferior turbinate hypertrophy, while 19(76%) patients had grade III before surgery. In the 3rd month after surgery, 22(88%) patients had grade I while 3(12%) patients had grade II inferior turbinate (P value<0.05). In his study, Friedman et al had 74(32%) grade II and 158(68%) grade III inferior turbinate before surgery. After surgery, they observed 166(72%) grade I and 66(28%) grade II inferior turbinate. In comparison, Hegazy H. et al had 10(11%) grade II and 80(89%) grade III inferior turbinate before surgery. After surgery, they observed 85(94%) grade I and 5(6%) grade II. So, we found that our results are similar to these studies because we apply the same methods and procedures used in these studies. In our study, we depend on 3months follow up while in the study of Friedman et al, they used 6months follow up, and Hegazy H.et al used 8weeks

follow up. We chose this period because the healing process nearly completed and all the complications appeared at this time.

During our procedure, we had 6(24%) patients that developed mucosal tear in the mucosal flap without mucosal loss, while in Friedman et al study there were fairly common in 55% of the patients. In contrast, in the study of Hegazy H.et al the mucosal tears were in 42(47%) turbinates mainly in cases with thin mucosa. In other study to Huang and Cheng(43), 5 patients (10%) had mucosal tears. Compared with studies of Friedman and Hegazy that used microdebrider blades (3.5 or 4.0mm). In our study, we used newly designed much smaller blade (2.0mm) incorporated with an elevator for protection of mucosal flap, causing less complications such as mucosal tears, bleeding and synechia.

Regarding bleeding, no one of our patients (0%) develops major bleeding per-operatively, while post-operatively ( at time of pack removal/48 hours) there is mild bleeding reported in 2 patients(8%), required only digital pressure to stop. In his study, Friedman et al reported two patients (1.6%) that develop postoperative bleeding that required a return to the operating room. In contrast, Huang and Cheng reported no patients had any postoperative bleeding after removal of the nasal packing after 24 hours. Our results were due to use of 2.0mm microdebrider blade and Merocel nasal packs which cause less mucosal injuries and bleeding at time of packs removal.

In our postoperative evaluation( 1st month), we observed 2patients(8%) that had crust formation, then after instructing the patients to use nasal saline wash along with antibiotics for 2weeks, the crust disappeared.In comparison, Friedman et al did not observe any crust formation, while Hegazy H.et al reported mild crusting and dryness in 5 of 50 patients(10%). Our results were probably due to mucosal tearing that happened during procedure and due to dry climate of our country.

Conclusion:

The result of this study revealed that the outcomes of powered-assisted endoscopic inferior turbinoplasty were significant in relieving the nasal obstruction, and it is a safe method in reduction of turbinate size with few postoperative complications.

Recommendations:

1. Increase number of patients with longer follow-up period in future studies.

2. Compare this technique with other techniques used in reduction the size of inferior turbinate.

3. We recommend to use powered-assisted endoscopic inferior turbinoplasty for reduction of turbinate size.

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