Effect of Septoplasty on Inferior Turbinate Hypertrophy

ORIGINAL ARTICLE Effect of Septoplasty on Inferior Turbinate Hypertrophy

Dong Hyun Kim, MD; Hun Yi Park, MD; Ho Sung Kim, MD; Sung Ook Kang, MD; Jung Sub Park, MD; Nam Soo Han, MD; Hyun Jun Kim, MD

Objective: To measure the effect of septoplasty on the sectional area of turbinate before and after septoplasty volume of inferior turbinate in patients with a deviated were compared using the Wilcoxon signed rank test. nasal septum. PϽ.05 was considered statistically significant.

Design: In this retrospective analysis, patients who Results: The medial mucosa and cross-sectional area of underwent septoplasty without turbinate surgery from the inferior turbinate on the concave side of the septum May 1, 2003, through April 30, 2006, were studied. The were significantly decreased by septoplasty (both, P=.01), thicknesses and cross-sectional areas of mucosa and and the medial mucosa and cross-sectional area of the conchal bones were measured with computed tomogra- inferior turbinate on the convex side of the septum were phy before the operations and at least 1 year after the significantly increased by septoplasty (P=.01). The thick- operations. nesses and cross-sectional areas of the conchal bone on the concave and convex sides of the septum were not af- Setting: University hospital. fected by septoplasty. Patients: A total of 20 patients who presented with a Conclusion: After septoplasty, inferior turbinate hyper- chief concern of nasal obstruction. trophy, especially in the medial mucosa, may reverse. Main Outcome Measures: The thicknesses of the medial mucosa, bone, and lateral mucosa and the cross- Arch Otolaryngol Head Neck Surg. 2008;134(4):419-423

S MUCH AS 75% TO 80% OF increased risk of morbidity, primarily hem- the general population is orrhage, intranasal adhesions, and atro- estimated to exhibit some phic rhinitis. In this study, we measured type of anatomical defor- the inferior turbinate before and after sep- mity of the nose,1 most toplasty to determine whether the changes commonlyA a deviated nasal septum. This in the inferior turbinate are permanent or deviation is often associated with over- reversed by septoplasty. growth of the inferior turbinate, which oc- cupies much of the contralateral nasal cavity.2-4 Accordingly, turbinate surgery is METHODS routinely performed in conjunction with septoplasty in patients with nasal obstruc- We reviewed ostial meatal unit computed to- tion and septum deviation. However, the mographic (CT) (HiSpeed Advantage model Author Affiliations: indications for turbinate surgery are not 17710CN1; GE Medical Systems, Milwaukee, Department of well defined, and surgical techniques vary Wisconsin) images of 20 patients who had un- Otolaryngology–Head and Neck substantially among rhinologic sur- dergone septoplasty without turbinate sur- Surgery, Our Lady of Mercy geons. A previous study2 established that gery at our hospital from May 1, 2003, through Hospital, The Catholic hypertrophy of the mucosa and the con- April 30, 2006. The CT scans were acquired University of Korea, Inchon chal bone of the inferior turbinate occurs on a 4-channel scanner (Genesis-zeus; GE (Dr D. H. Kim), and in patients with nasal septal deviation, Medical Systems) with axial and coronal scans. Departments of Otolaryngology We used a tube voltage of 120 kilovolt peak (Drs H. Y. Park, Kang, but data were insufficient to determine (kVp) in combination with 200 to 230 mA sec- J. S. Park, Han, and H. J. Kim) whether these changes are permanent or onds, a section thickness of 5 mm, and a field and Radiology (Dr. H. S. Kim), reversible by septoplasty. When per- of view of 512ϫ512 mm. Images were taken Ajou University School of formed as an adjunct to septoplasty, infe- for evaluation of nasal obstruction. The study Medicine, Suwon, South Korea. rior turbinate surgery is associated with an group consisted of patients who had not re-

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 measured as for the inferior turbinate bone. A radiologist (H.S.K.) Table 1. Clinical Characteristics of the Study Patientsa and 2 otolaryngologists (D.H.K. and H.J.K.) who reviewed the CT scans were blinded. The measurements conducted by the Sex/ Date of Date of Follow-up Deviated Deviated radiologist and 2 otolaryngologists were averaged. Age, y First CT Second CT Duration, mo Side Shape Group means were compared for statistical significance using M/22 Mar 2003 Jul 2005 28 L C the Wilcoxon signed rank test and SAS statistical software (SAS M/24 Jan 2004 Jul 2005 18 L C version 8.1; SAS institute Inc, Cary, North Carolina). Results M/25 Mar 2004 Apr 2005 13 L C are presented as means(SDs). PϽ.05 was considered statisti- F/21 Jan 2004 Jul 2005 18 R C cally significant. M/30 Dec 2003 Aug 2005 20 L C M/33 Jul 2003 Aug 2005 25 R C F/34 Oct 2003 Aug 2005 22 R C RESULTS M/35 Jul 2003 Aug 2005 25 R C M/35 Jun 2003 Aug 2005 26 R C On the concave side of the septum, septoplasty signifi- M/35 Jul 2003 Aug 2005 25 L C M/36 Sep 2003 Aug 2005 23 R C cantly decreased the thickness of the medial mucosa of F/37 Jul 2003 Aug 2005 25 L C the inferior turbinate by 1 mm (P=.01) and decreased M/39 Jul 2004 Jan 2006 18 L C the mean dimensions of inferior turbinate by 18 mm2 M/46 Nov 2004 Feb 2006 15 R C (P=.01). On the convex side of the septum, septoplasty M/52 Dec 2004 Feb 2006 14 L C significantly increased the thickness of the medial mu- M/60 Oct 2004 Feb 2006 16 R C cosa of the inferior turbinate by 1 mm (P=.01) and in- M/66 Oct 2004 Mar 2006 17 L C M/35 Sep 2003 Apr 2006 31 L S creased the mean dimensions of inferior turbinate by 14 2 F/56 Nov 2003 Aug 2005 21 R C mm (P=.01). Septoplasty did not change the thickness M/22 Nov 2004 Jan 2006 14 L S or mean dimensions of inferior conchal bone on the concave or convex side of the septum (Table 2 and Table 3). Abbreviations: C, in the shape of the letter C; CT, computed tomography; S, in the shape of the letter S. a All patients had deviations in both the cartilage and bone. COMMENT

ceived topical corticosteroids, antiallergenic medications, or any Otorhinolaryngologists have long recognized that when adjunctive medical drugs at least 2 weeks before CT. Patients the nasal septum is deviated toward one side the excess who had received turbinate surgery or septoplasty were ex- space in the opposite nasal cavity is occupied by hyper- cluded from the study. trophic nasal turbinates.5 Hypertrophy of the contralat- Conducting CT preoperatively and at least 1 year after sep- eral inferior turbinate is thought to be compensatory to toplasty, we compared the preoperative CT scan with the post- deflection of the nasal septum because the hypertrophy operative scan. The study population consisted of 20 patients protects the more patent passage from excess airflow, (16 men [80%] and 4 women [20%]) between 21 and 66 years which has drying and crusting effects on nasal mucous of age (mean [SD], 37.2[12.9] years). All patients in the study membranes.3,4 However, enlargement of the inferior tur- had septal deviation that included both cartilage and bony com- binate significantly increases nasal airway resistance, con- ponents (perpendicular plate of ethmoid and vomer) (Table 1). The window width and level of CT were controlled to al- tributing greatly to symptoms of nasal airway obstruc- low visualization of mucosal and ostial lesions. In all cases, tion. An alternative explanation concerns primary 5-mm-thick high-resolution coronal CT sections were ana- unilateral growth of the turbinate bone, which can be ge- lyzed with ␲-View software (version 5.0.5.2; Infinitt, Seoul, Ko- netic or can be caused by trauma in early life.3 Unilat- rea). The measurements were made at the anterior, middle, and eral growth of the turbinate bone may exert pressure on posterior thirds of the inferior turbinate in coronal sections. the growing nasal septum during childhood and adoles- For standardization, anterior measurement was performed on cence and eventually cause it to bend toward the other the first image in which the entire inferior turbinate bone could side of the nose. Although most physicians have adopted be identified. The middle measurement was performed on the the first theory, observations of increased bone growth section in which the uncinate process and maxillary sinus os- rather than mucosal growth lend credibility to the sec- tium were visualized (Figure 1). The posterior measurement was performed on the last image in which the entire inferior ond theory. Nevertheless, to our knowledge, no pub- turbinate bone could be identified. All images were magnified lished scientific evidence substantiates either theory, and to facilitate accurate measurement. the association between the 2 phenomena has not yet been The thicknesses of the medial mucosa, bone, and lateral mu- determined.3 cosa were measured separately at the anterior, middle, and pos- Since the first surgical procedure for turbinate reduc- terior portions of the inferior turbinate on a plane perpendicu- tion, performed by Hartmann in the 1890s, many other lar to the mucosal surface in the inferior turbinate with the aid techniques have been developed.6 However, inferior tur- of a cursor on the CT scanner screen. The thicknesses before binate surgery as an adjunct to septoplasty is associated and after septoplasty were compared for the anterior, middle, with increased morbidity, primarily hemorrhage, intra- and posterior aspects of the turbinates. The boundary of the nasal adhesions, and atrophic rhinitis. The incidence of inferior turbinate bone was outlined on bone-window CT images (width, 1500 Hounsfield units [HU]; level, 300 HU) hemorrhage in patients undergoing septal surgery alone (Figure 2), and the corresponding area was measured using is less than 2% as opposed to 6% in patients undergoing 7 ␲-View software. The outline of the inferior turbinate was mea- septal surgery with turbinate surgery. The incidence of sured using the soft tissue window (width, 150 HU; level, adhesions increases from 5% to 17% with the addition 40 HU) (Figure 3), and the overall cross-sectional area was of turbinate surgery to a septal surgical procedure.8

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5 mm 4 mm

Figure 1. Coronal computed tomogram through the middle portion of the inferior turbinate. The tomogram shows the dimensions of the medial mucosa on the concave side of the septum before septoplasty (A) and after septoplasty (B).

A B

32 mm2 32 mm2

Figure 2. Coronal computed tomogram through the middle portion of the inferior turbinate. The tomogram shows the boundary of the inferior turbinate bone outlined on the bony window before septoplasty (A) and after septoplasty (B).

A B

118 mm2 107 mm2

Figure 3. Coronal computed tomogram through the middle portion of the inferior turbinate. The tomogram shows the boundary of the inferior turbinate outlined on the soft tissue window before septoplasty (A) and after septoplasty (B).

The incidence of atrophic rhinitis is 5% to 49% with surgery represent the pathophysiologic basis of nasal dry- turbinate surgery.9,10 Because the turbinates play an im- ing and crusting.7 portant role in nasal physiology by warming and hu- The primary goal of therapy is to maximize the nasal midifying inspired air, the increased airflow and macro- airway for as extended a period as possible while mini- turbulence throughout the nasal cavities after turbinate mizing complications of therapy, such as nasal drying,

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Table 2. Thickness of the Medial and Lateral Mucosa and Conchal Bone Before and After Septoplasty

Concave Convex

Preoperative Postoperative Paired Preoperative Postoperative Paired Thickness, Thickness, Difference, Thickness, Thickness, Difference, Mean (SD), Mean (SD), Mean (SD) P Mean (SD), Mean (SD), Mean (SD) P Area mm mm [95% CI] Value mm mm [95% CI] Value Medical Mucosa Anterior (n=20) 5 (1) 5 (1) 0.86 (0.95) [0.42 to 1.30] .01 3 (1) 4 (1) −0.80 (1.22) [−1.37 to −0.23] .01 Middle (n=20) 5 (1) 4 (1) 0.94 (0.92) [0.52 to 1.37] .01 3 (1) 3 (1) −0.30 (0.82) [−0.69 to 0.08] .12 Posterior (n=20) 5 (1) 5 (1) 0.67 (1.08) [0.17 to 1.18] .01 4 (1) 4 (1) −0.14 (0.99) [−0.60 to 0.32} .54 Total (N=60) 5 (1) 4 (1) 0.77 (0.98) [0.50 to 1.05] .01 3 (1) 4 (1) −0.43 (0.99) [−0.71 to −0.15} .01 Lateral Mucosa Anterior (n=20) 3 (1) 2 (1) 0.36 (0.65) [0.06 to 0.67] .09 2 (1) 2 (1) −0.08 (0.70) [−0.41 to 0.25] .75 Middle (n=20) 3 (1) 3 (1) 0.38 (0.70) [0.05 to 0.70] .15 2 (1) 3 (1) −0.13 (0.77) [−0.50 to 0.23] .35 Posterior (n=20) 3 (1) 3 (1) 0.47 (0.82) [0.08 to 0.85] .02 3 (1) 3 (1) −0.21 (0.74) [−0.55 to 0.14] .46 Total (N=60) 3 (1) 3 (1) 0.32 (0.68) [0.13 to 0.52] .01 2 (1) 2 (1) −0.16 (0.73) [−0.36 to 0.05] .31 Conchal Bone Anterior (n=20) 3 (1) 3 (1) 0.03 (0.42) [−0.17 to 0.23] .84 2 (1) 2 (1) 0.05 (0.48) [−0.17 to 0.27] .37 Middle (n=20) 4 (1) 4 (1) 0.21 (0.80) [−0.17 to 0.58] .86 3 (1) 3 (1) −0.23 (0.75) [−0.58 to 0.12] .21 Posterior (n=20) 3 (1) 3 (1) −0.08 (0.45) [−0.29 to 0.14] .51 3 (1) 3 (1) 0.00 (0.55) [−0.25 to 0.26] .86 Total (N=60) 3 (1) 3 (1) −0.06 (0.51) [−0.20 to 0.09] .66 3 (1) 3 (1) −0.07 (0.62) [−0.24 to 0.11] .77

Abbreviation: CI, confidence interval.

Table 3. Mean Dimensions of Inferior Turbinate and Inferior Conchal Bone Before and After Septoplasty

Concave Convex

Preoperative Postoperative Paired Preoperative Postoperative Paired Dimension, Dimension, Difference, Dimension, Dimension, Difference, Mean (SD), Mean (SD), Mean (SD) P Mean (SD), Mean (SD), Mean (SD) P Area mm2 mm2 [95% CI] Value mm2 mm2 [95% CI] Value Inferior Turbinate Anterior (n=20) 153 (37) 133 (37) 18.49 (28.27) [5.26 to 31.72] .01 94 (22) 108 (34) −13.67 (26.13) [−25.90 to −1.44] .09 Middle (n=20) 168 (39) 152 (42) 14.74 (28.83) [1.24 to 28.23] .06 99 (32) 115 (41) −13.31 (25.43) [−25.21 to −1.40] .04 Posterior (n=20) 158 (35) 140 (35) 17.15 (24.15) [5.85 to 28.46] .01 114 (32) 125 (33) −8.84 (26.65) [−21.31 to 3.63] .17 Total (N=60) 160 (37) 142 (38) 18.11 (28.70) [10.04 to 26.18] .01 103 (30) 116 (36) −13.63 (26.43) [−21.06 to −6.20] .01 Conchal Bone Anterior (n=20) 25 (6) 23 (9) 1.96 (4.63) [−0.21 to 4.12] .10 20 (10) 23 (8) −4.01 (6.90) [−7.24 to −0.79] .10 Middle (n=20) 29 (10) 29 (11) 0.68 (4.04) [−1.22 to 2.57] .97 23 (9) 22 (11) 0.29 (7.26) [−3.11 to 3.69] .93 Posterior (n=20) 18 (7) 18 (8) −0.42 (5.59) [−3.03 to 2.20] .32 18 (8) 16 (7) 1.65 (4.97) [−0.67 to 3.97] .24 Total (N=60) 23 (9) 23 (11) 0.73 (4.68) [−0.59 to 2.04] .12 20 (9) 20 (9) −0.19 (6.45) [−2.00 to 1.63] .62

Abbreviation: CI, confidence interval.

hemorrhage, and atrophic rhinitis. Although appropri- ditions created by the septoplasty. According to the Poi- ate treatment is of great importance to patients with na- seuille law, which states that flow through a tube is pro- sal obstruction, more scientific data are needed to fully portional to the fourth power of the radius or to the square justify the benefits of turbinate surgery.2,3 The present of the cross-sectional area of the tube, a 10% increase in indications for turbinate surgery are based on empirical the cross-sectional area of the nasal passage will result in a criteria and have resulted in extensive, unnecessary, or 21% increase in airflow through the nose.13 This means that insufficient surgery without objective evaluation.9,11,12 In- slight variations in the size of the soft tissue and/or bone appropriate selection of surgery as a therapeutic option of the inferior turbinate can have large effects on nasal air- and inappropriate choice of surgical modality seem to be flow.4 The reversal of enlargement of turbinate soft tissue the major causes of patient dissatisfaction. observed in our study may have relieved nasal obstruc- This study has several limitations, including the lack of tion by increasing the cross-sectional area of the nasal air- evaluation of the nasal cycle. However, we showed that hy- way. Therefore, we propose further study evaluating pertrophy of the inferior turbinate was modified by septo- whether turbinate surgery can be conducted as a staged op- plasty. In particular, hypertrophy of the medial mucosa was eration with septoplasty in patients with mucosal hyper- reversed and the mucosa adapted to the new spatial con- trophy of the inferior turbinate. Although we identified that

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 septoplasty without turbinate surgery induced a reduc- Wonchon-dong, Youngtong-gu, Suwon 443-721, South tion in mucosal thickness, especially that of the medial mu- Korea ([email protected]). cosa, we did not identify how long this effect takes to oc- Author Contributions: All of the authors had full ac- cur. Illum14 reported that, 5 years after surgery, the impact cess to all the data in the study and take responsibility of turbinate reduction was reduced and the satisfaction of for the integrity of the data and the accuracy of the data patients with the procedure was similar to that of patients analysis. Study concept and design: H. J. Kim. Acquisition who underwent septoplasty only. It was postulated that the of data: D. H. Kim, H. Y. Park, H. S. Kim, Kang, J. S. Park, reduction of mucosal edema after septal surgery is likely Han, and H. J. Kim. Analysis and interpretation of data: the result of diminished submucosal blood circulation.15 D. H. Kim, H. S. Kim, and H. J. Kim. Drafting of the manu- The tendency of the turbinate to adapt and fit into the new script: D. H. Kim, H. Y. Park, H. S. Kim, Kang, J. S. Park, spatial conditions created after septoplasty14 is associated and Han. Critical revision of the manuscript for impor- with bone resorption, a process that probably develops many tant intellectual content: H. J. Kim. Statistical analysis: months and even years after surgery.3 We consider that the D. H. Kim and Kang. Study supervision: H. J. Kim. effect reported by Illum14 is probably related to the phe- Financial Disclosure: None reported. nomenon that septoplasty induces a reduction of mucosal thickness even without turbinate surgery. 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