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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 46  |  Issue : 1  |  Page : 16-22

Surface linear versus submucosal cauterization using radiofrequency for the management of inferior turbinate hypertrophy


Department of Otolaryngology, Faculty of Medicine, Tanta University Hospitals, Tanta, Egypt

Date of Submission10-Jul-2017
Date of Acceptance12-Nov-2017
Date of Web Publication26-Jul-2018

Correspondence Address:
Shimaa G El-Gamalah
Department of Otolaryngology, Faculty of Medicine, Tanta University Hospitals, Mahalat Marhoum, Tanta, Gharbia Governorate, 31719
Egypt
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DOI: 10.4103/tmj.tmj_67_17

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  Abstract 


Background and aim Inferior turbinate hypertrophy is one of the major causes of nasal obstruction. Radiofrequency thermal ablation (RFTA) is a technique in which high-frequency current passes quickly through the target tissue to cause a reduction in tissue amount through ablation by heat. In RFTA application, initially, a coagulation necrosis is formed in the tissue, then, tissue ablation is occurred through recovery. The aim of this work was to evaluate and compare the effectiveness of surface linear versus submucosal cauterization by using radiofrequency in the management of hypertrophied inferior turbinates.
Patients and methods Patients who had bilateral nasal obstruction caused by only inferior turbinate hypertrophy underwent surgical treatment by surface linear cauterization for right hypertrophied inferior turbinate and submucosal cauterization for left hypertrophied inferior turbinate using radiofrequency with 0° telescope under general anesthesia. Information was collected regarding nasal obstruction, crust formation, adhesions and patient satisfaction. The data were recorded at 1 week, 1, 3, and 6 months postoperatively based on a 10-point visual analogue scale.
Results Regarding nasal obstruction, significant difference was found between both techniques only at 1 week after intervention in favor of surface group. Regarding crustation, significant difference was observed between both techniques at 1 week, 1, and 3 months. Regarding satisfaction, significant difference was seen between both techniques at 1 week, 1, and 3 months. Regarding adhesion, significant difference was seen between both techniques only at 1 week.
Conclusion Surface linear method may lead to crust formation and more adhesions.

Keywords: inferior turbinate hypertrophy, radiofrequency, submucosal cauterization, surface cauterization


How to cite this article:
El-Gamalah SG, Behery ABS, Hamad MH, Aglan YI. Surface linear versus submucosal cauterization using radiofrequency for the management of inferior turbinate hypertrophy. Tanta Med J 2018;46:16-22

How to cite this URL:
El-Gamalah SG, Behery ABS, Hamad MH, Aglan YI. Surface linear versus submucosal cauterization using radiofrequency for the management of inferior turbinate hypertrophy. Tanta Med J [serial online] 2018 [cited 2018 Oct 17];46:16-22. Available from: http://www.tdj.eg.net/text.asp?2018/46/1/16/237627




  Background Top


The inferior turbinates are highly vascular structures that extend from the front of the nose along the side of the nasal floor all the way back toward the opening into the throat (nasopharynx).

These are the only structures within the nasal cavity that freely swell and shrink on a routine basis (the nasal cycle). When these structures are enlarged (hypertrophied) especially at the front of the nose, they can cause significant functional obstruction. In many instances, patients with inferior turbinate hypertrophy can be managed with medical and antiallergic treatments. In other cases, surgical reduction of the inferior turbinates may be indicated [1].

One of the major causes of nasal obstruction is inferior turbinate hypertrophy; other causes include septal deviation and nasal polyps. The etiology of inferior turbinate hypertrophy is allergic rhinitis, vasomotor rhinitis, and compensatory hypertrophy to septal deviation [2].

There are multiple methods for surgical management of inferior turbinate hypertrophy such as mucosa-sparing techniques, microdebrider-assisted inferior turbinoplasty (MAIT) [3], submucosal electrocautery [4], submucous turbinectomy, inferior turbinoplasty, cryotherapy, submucous electrosurgery, and carbon dioxid laser turbinoplasty [5].

Radiofrequency thermal ablation (RFTA) is a technique in which high-frequency current passes quickly through the target tissue to cause a reduction in tissue amount through ablation by heat. In RFTA application, initially, a coagulation necrosis is formed in the tissue, then, tissue ablation is occurred through recovery [6].

The aim of this work was to evaluate and compare the effectiveness of surface linear versus submucosal cauterization by using radiofrequency in the management of hypertrophied inferior turbinates.


  Patients and methods Top


Study design

This was a prospective nonrandomized controlled trial.

All patients with bilateral inferior turbinate hypertrophy, who were eligible for reduction surgery during the study period, have been included in the study.

Patients were recruited from the ORL-HNS Department, Tanta University Hospital, starting from February 2016 to July 2016.

Patients enrolled in this study met the following criteria:
  1. Adult patients aged from 16 to 50 years.
  2. All patients were presented by symptoms and signs of bilateral nasal obstruction related to hypertrophy of the inferior turbinate that had not responded to medical treatment.


The following patients were excluded from this study:
  1. Patients with unilateral hypertrophy of the inferior turbinate.
  2. Children and pregnant ladies.
  3. Patients having a prior history of sinus or nasal surgery.
  4. Patients with nasal septal deviation, nasal polyps, or tumors.
  5. Patients with chronic sinusitis.
  6. Patients responding to antihistamines and/or topical steroid.


All patients were subjected to the following:
  1. Preoperative evaluation
    1. Full history taking.
    2. Complete clinical examination.
    3. Nasal endoscopic examination.
    4. Coronal paranasal diagnostic computed tomography scan for all patients.
    5. Symptoms evaluation.

      A standard visual analogue scale (VAS) ranging from 0 (no symptoms) to 10 (most severe) was used to assess three subjective symptoms: nasal obstruction, postoperative crust formation, and adhesions. Patient’s overall postoperative satisfaction was also graded on a VAS ranging from 0 (complete satisfaction) to 10 (complete dissatisfaction).
    6. Preoperative laboratory investigations included the following:
      1. Complete blood picture.
      2. Prothrombin time.
      3. Partial thromboplastin time.
      4. Bleeding time.
      5. Hepatitis C virus and hepatitis B virus.
    7. Full counseling of all patients for surgery and informed consents were obtained.
    8. All patients selected for this study were assigned to undergo surface linear cauterization for right hypertrophied inferior turbinate and submucosal cauterization for left hypertrophied inferior turbinate using radiofrequency with 0° telescope under general anesthesia.


Procedures

Surface linear procedure

Application of three linear streaks on the medial surface of the hypertrophied inferior turbinate of the right side for ∼60–90 s was done.

The instrument was set to 85°C and 460 J.

Submucosal procedure

The hypertrophied inferior turbinate of the left side was subjected to submucosal cauterization using equipment including the radiofrequency generator connected to specialized delivery tip with thermocouples allowing intramural application of the radiofrequency energy limiting partial injury to the mucosa.
  1. A grounding pad was applied to the patient flank to return the radiofrequency current to the generator in both procedures.
  2. Continuous blood pressure, heart rate, oxygen saturation measurements were monitored during operation. Nasal packing was not required for any patient after both procedures.
  3. Collection of information regarding nasal obstruction, crust formation, adhesions, and patient satisfaction was done. The data were recorded at 1 week, 1, 3, and 6 months postoperatively based on a 10-point VAS.
  4. Every patient was examined in an outpatient clinic using 00 telescope with xylocaine spray.


Statistical analysis

The collected data were coded, fed to the computer, and analyzed using IBM SPSS software package version 20.0 (S&S Office, Alexandria). Paired t-test was used to compare for normally distributed quantitative variables, to compare between two periods. For normally quantitative periods, post-hoc test (Bonferroni adjusted) was used for pairwise comparisons whereas Wilcoxon signed rank test for abnormally quantitative periods. Friedman test was used for abnormally distributed quantitative variables, to compare between more than two periods or stages. McNemar–Bowker test was used to analyze the significance between the different stages.


  Results Top


Overall, 40 patients with bilateral hypertrophied inferior turbinate (excluding other causes of nasal obstruction) in different age and sex groups having a history of long-standing nasal obstruction refractory to medical treatment were included in this study.

Average nasal obstruction degree caused by hypertrophied inferior turbinate in group A (surface group) was 8.6 by VAS preoperatively, which decreased to 5.20 at 1 week, to 3 after 1 month, to 2.43 after 3 months, and to 2.40 6 months later. This recorded decrease was found to be statistically significant (P<0.001).

As for group B (submucosal group), it was 8.6 by VAS preoperatively, which decreased to 6.70 at 1 week after intervention, to 3.10 after 1 month, to 2.45 after 3 months, and to 2.40 6 months later. This recorded decrease was found to be statistically significant (P<0.001).

When comparing the two groups, a significant difference between both the techniques was found only at 1 week after intervention (P<0.001), whereas a nonsignificant difference was found between both techniques at the following time periods:
  1. At 1 month after intervention (P=0.562).
  2. At 3 month after intervention (P=0.570).
  3. At 6 month after intervention (P=1.000) ([Table 1] and [Figure 1]).
    Table 1 Comparison between the different periods according to obstruction

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    Figure 1 Comparison between the different periods according to obstruction.

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Crustation in group A decreased from 8.2 at 1 week after intervention to 3.9 after 1 month, to 0.50 after 3 months, and to 0.00 6 months later. This recorded decrease was found to be statistically significant (P<0.001).

As for group B, it decreased from 1.9 at 1 week after intervention to 0.20 after 1 month, to 0.00 after 3 months, and to 0.00 6 months later. This recorded decrease was found to be statistically significant (P<0.001).

When comparing the two groups, a significant difference was found between both techniques at the following time periods:
  1. At 1 week after intervention (P<0.001).
  2. At 1 month after intervention (P<0.001)
  3. At 3 month after intervention (P<0.001).


However, a nonsignificant difference was found between both the techniques at 6 month after intervention (P=1.000) ([Table 2] and [Figure 2]).
Table 2 Comparison between the different periods according to crustation

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Figure 2 Comparison between the different periods according to crustation.

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Satisfaction of patients with hypertrophied inferior turbinate in group A (surface group) was reported at 8.6 by VAS preoperatively, which decreased to 5.90 at 1 week after intervention, to 2.15 after 1 month, to 1.15 after 3 months, and to 0.30 6 months later. This recorded decrease was found to be statistically significant (P<0.001).

As for group B (submucosal group), it was 8.6 by VAS preoperatively, which decreased to 3.70 at 1 week after intervention, to 1.30 after 1 month, to 0.48 after three months, and to 0.30 6 months later. This recorded decrease was found to be statistically significant (P<0.001).

When comparing the two groups, a significant difference was found between both the techniques at the following periods:
  1. At 1 week after intervention (P<0.001).
  2. At 1 month after intervention (P<0.001).
  3. At 3 month after intervention (P=0.003).


However, a nonsignificant difference was found between both the techniques at 6 months after intervention (P=1.000) ([Table 3] and [Figure 3]).
Table 3 Comparison between the different periods according to satisfaction

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Figure 3 Comparison between the different periods according to satisfaction.

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Adhesions were seen in 12 (30%) patients in group A and four (10%) patients in group B at 1 week and then decreased to zero in both groups after intervention at 1, 3, and 6 months.

When comparing the two groups, a significant difference was found between both the techniques only at 1 week period (P=0.021) ([Table 4] and [Figure 4]).
Table 4 Comparison between the different periods according to adhesion

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Figure 4 Comparison between the different periods according to adhesion.

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  Discussion Top


Chronic nasal obstruction is one of the commonest complaints made by the patients to their otolaryngologists [7].

Although it is not a life-threatening condition, nasal obstruction can interfere with the quality of life. If septal problems are excluded, the main structures contributing to this problem are the nasal turbinates, specially the inferior turbinate [8].

In case of nonresponse to conservative medical management, the surgical reduction of the inferior turbinate is required [9].

Radiofrequency volume tissue reduction, first described in 1995 by Powel et al. [10], has emerged as an effective alternative in the treatment of nasal turbinate hypertrophy [11].

In this study, 40 patients with bilateral hypertrophied inferior turbinate (excluding other causes of nasal obstruction) in different age and sex groups having a history of long-standing nasal obstruction refractory to medical treatment were selected.

Every patient was subjected to surface linear cauterization for the right side and submucosal cauterization for the left one using Ellman Surgitron (FFPF).

Subjective questionnaire, nasal examination, and nasal endoscopy were used to evaluate each patient. Patients were evaluated at 1 week, 1, 3, and 6 months postoperatively for nasal obstruction, crust formation, adhesion, and patient satisfaction.

In this study, a significant improvement in nasal obstruction and patient satisfaction was noted in both groups, whereas postoperatively, crusting and adhesions were observed markedly in group A, especially at 1 week and 1 month.

In surface method, degree of nasal obstruction was reduced from 8.60±1.03 to 2.40±0.50 (P<0.001).

Crusting was observed on the surface of the turbinate up to the third month.

Adhesions were observed in the first week in 30% of patients and disappeared after the management of it.

Patient satisfaction was reduced from 8.60±1.03 to 0.30±0.46 (P<0.001).

In submucosal method, degree of nasal obstruction was reduced from 8.60±1.03 to 2.40±0.50 (P<0.001).

Crusting was observed on the surface of the turbinate in the first week and 1 month in some patients and then disappeared.

Adhesions were observed in the first week in 10% of patients and disappeared after the management of it.

Patient satisfaction was reduced from 8.60±1.03 to 0.30±0.46 (P<0.001).

Crusting and adhesions were cleared regularly in OPD with local anesthetic spray (10% xylocaine).

We could not find any paper written using radiofrequency in the application of surface cauterization to save the mucosa of the turbinate, but the surface method was applied only by diathermy.

Imran et al. [12] reported in their study for the treatment of hypertrophied inferior turbinate using diathermy that patency of the nose was checked in all 30 patients of group A (surface cautery), fully blocked in first to second weeks. In fourth week, all 30 patients were partially blocked. In group B (submucosal cautery), all 30 patients were fully blocked in the first week. There was no difference statistically between the two groups in the first week (P>0.05). In fourth week, 19 patients were partially blocked, and 11 patients were fully patent. In second, third, and fourth follow-up weeks, there was statistically significant difference (P<0.001). In the first week, crusting was seen in all patients of group A and 10 (33.3%) patients in group B. Adhesions were noted in 40% of group A and 16.7% of group B. In the fourth week, crusting was seen in 30.0% of patients in group A and 6.7% of patients in group B. Adhesions were noted in 23.3% of patients in group A and 3.3% of patients in group B.Mehmet et al. [13] reported mild congestion and crusting in the noses of the patients who underwent radiofrequency during the first week after the procedure. Turbinate edema and nasal obstruction in the treated patients were recovered after 1 month of treatment (P<0.01).

Matthew et al. [14] reported that the severity of obstruction decreased in all patients, with mean scores of 7.7 and 4.9 for pretreatment and 6 month follow-up, respectively.

All changes in VAS scores (8 week and 6 months) were statistically significant (P<0.01).


  Conclusion Top


Surface linear and submucosal cauterization are safe, easy, less morbid, and effective method in reducing turbinate volume with improvement in the symptoms of nasal obstruction secondary to turbinate hypertrophy, no intraoperative hemorrhage, no need for postoperative nasal packing, and can be done as an office procedure, but surface linear method may lead to crust formation and more adhesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Faure C, Seghir C, Hamon M, Seghir A, Mouriaux F. Orbital apex syndrome following inferior turbinate radiofrequency. Rev Laryngol Otol Rhinol (Bord) 2009; 130:121–123.  Back to cited text no. 1
    
2.
Hamerschmidta R, Hamerschmidtb R, Moreirab AT, Tenório SB, Ribas Timi JR. Comparison of turbinoplasty surgery efficacy in patients with and without allergic rhinitis. Braz J Otorhinolaryngol 2015; 265:1–9.  Back to cited text no. 2
    
3.
Cingi C, Ure B, Cakli H, Ozudogru E. Microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty: a prospective study with objective and subjective outcome measures. Acta Otorhinolaryngol Ital 2010; 30:138–143.  Back to cited text no. 3
    
4.
Barham HP, Thornton MA, Knisely A, Marcells GN, Harvey RJ, Sacks R. Long-term outcomes in medial flap inferior turbinoplasty are superior to submucosal electrocautery and submucosal powered turbinate reduction. Int Forum Allergy Rhinol 2016; 6:143–147.  Back to cited text no. 4
    
5.
Saulescu M, Sarafoleanu C. Surgery for nasal obstruction in inferior turbinate hypertrophy. Eur Respir J 2015; 5:25–30.  Back to cited text no. 5
    
6.
Uz AO, Kenar F, Yıldız H, Duran A, Tekin MS, Ayçiçek A. The effect of radiofrequency thermal ablation method on nasal mucociliary activity in patients with inferior turbinate hypertrophy. Kulak Burun Bogaz Ihtis Derg 2014; 24:247–253.  Back to cited text no. 6
    
7.
Saunder WH. Surgery of the inferior nasal turbinates. Ann Oto Rhinol Laryngol 1982; 91:445–447.  Back to cited text no. 7
    
8.
Passali D, Passali FM, Damiani V. Treatment of inferior turbinate hypertrophy a randomized clinical trial. Ann Otol Rhinol Laryngol 2003; 112:683–688.  Back to cited text no. 8
    
9.
Ferri E, Armato E, Caralari S. Argon plasma surgery for treatment of inferior turbinate hypertrophy: a long term follow up in 157 patient. ORL J Otorhinolaryngol Relat Spec 2003; 65:206–210.  Back to cited text no. 9
    
10.
Powell NB, Riley RW, Troell RJ, Blumen MB, Guilleminault C. Radiofrequency volumetric reduction of the tongue: a porcine pilot study for the treatment of obstructive sleep apnea syndrome. Chest 1997; 111:1348–1355.  Back to cited text no. 10
    
11.
Cavaliere M, Mottolo G, Lemma M. Monopolar and bipolar radiofrequency thermal ablation of inferior turbinates: 20 months follow up. Otolaryngol Head Neck Surg 2007; 137:256–263.  Back to cited text no. 11
    
12.
Imran S, Muhammad A, Abdur R. Comparison of the surface cautery and submucuos diathermy in relation to relief of nasal obstruction caused by hypertrophied inferior turbinates. PJMHS 2015; 9:629–632.  Back to cited text no. 12
    
13.
Mehmet A, Suleyman D, Fazil EO, Celik MY, Degirmenci A, Demir H, Meric F. Long term effect of radiofrequency turbinoplasty in nasal obstruction. Biotechnol Biotechnol Equip 2014; 28:285–294.  Back to cited text no. 13
    
14.
Porter MW, Hales NW, Nease CJ, Krempl GA. Long term results of inferior turbinate hypertrophy with radiofrequency treatment: a new standered of care. Laryngoscope 2006; 116:554–557.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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