Comparison of Radiofrequency and Microdebrider-Assisted Turbinoplasty for Treatment of Isolated Inferior Turbinate Hypertrophy

Eur J Rhinol Allergy 2019; 2(2): 51-6 Original Article

Zuhal Gül1 , Demet Aydoğdu2 , Çağatay Han Ülkü1

1Department of Otolaryngology - Head and Neck Surgery, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey 2Department of Radiology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey

Abstract Objective: The aim of this study was to compare the effectiveness and reliability of radiofrequency thermal ablation (RFTA) versus microdebrider submucosal resection (MSMR) techniques for the treatment of inferior turbinate hypertrophy. Material and Methods: Forty adult patients with chronic nasal obstruction due to isolated inferior turbinate hypertrophy were included in this study. Patients were randomly divided into two groups. Endoscopy-assisted RFTA was performed on group 1 patients and MSMR was performed on group 2 patients. To assess the sizes of the inferior turbinates, patients underwent paranasal magnetic resonance imaging (MRIs) pre- and post-operatively. Rhinomano- metric evaluation was performed pre- and post-operatively to evaluate the nasal resistance. Patients pointed out their level of nasal obstruction using a visual analog scale (VAS) pre- and post-operatively. The saccharine test was used to assess the mucociliary system activity pre- and post-operatively. Results: The post-operative mean inferior turbinate volumes, mean nasal resistance, and VAS scores were significantly lower in both groups when they were compared with the pre-operative values. Furthermore, post-operative mean turbinate volumes, mean nasal resistance, and VAS were significantly lower in group 2 as compared to group 1. The mucociliary clearance times measured pre- and post-operatively were not significantly different between the groups. Conclusion: This study revealed both techniques to be effective for treating turbinate hypertrophy and proved that they do not affect the mucociliary clearance system. Furthermore, this study demonstrated that MSMR is more effec- Cite this article as: tive and shows relatively rapid results as compared to RFTA. Gül Z, Aydoğdu D, Ülkü ÇH. Comparison of Keywords: Inferior turbinate, hypertrophy, radiofrequency microdebrider, treatment Radiofrequency and Microdebrider-Assisted INTRODUCTION Turbinoplasty for Treatment Nasal obstruction is one of the most common symptoms encountered in otorhinolaryngology practice. Inferior turbi- of Isolated Inferior Turbinate nate hypertrophy and nasal septal deviation frequently cause this symptom. Allergic rhinitis, rhinitis medicamentosa, Hypertrophy. Eur J Rhinol Allergy 2019; 2(2): 51-6. and vasomotor rhinitis increase the nasal resistance and are thought the main reasons for the occurrence of inferior turbinate hypertrophy. Despite performing effective medical treatment for the underlying pathology, inferior turbinate Address for Correspondence: hypertrophy may show resistance and additional therapy may be required. In these circumstances, pharmacologic Çağatay Han Ülkü therapy should be the first-line treatment and surgical treatment should be considered for patients without an ade- E-mail: quate response to the pharmacological therapy. The goals of inferior turbinate surgery are to provide an adequate nasal [email protected] passage for respiration with preserving basal functions of inferior turbinate and to minimize the possible complications Received: 23.05.2019 (1, 2). Consistent with this statement, clinicians have increasingly preferred surgical treatment options in recent years. Accepted: 25.07.2019 DOI: 10.5152/ejra.2019.151 In this study, we aimed to compare the effectiveness and reliability of radiofrequency thermal ablation (RFTA) versus ©Copyright 2019 by Turkish microdebrider submucosal resection (MSMR) techniques for the treatment of inferior turbinate hypertrophy. Data Rhinologic Society - Available from the magnetic resonance imaging (MRI), visual analog scale (VAS), and rhinomanometry were used as the pa- online at www.eurjrhinol.org rameters. 52 Gül et al. Comparison of Radiofrequency and Microdebrider Eur J Rhinol Allergy 2019; 2(2): 51-6

MATERIAL AND METHODS atively (in the 24th week) (Figure 3, 4). We measured the longitudinal and transverse lengths of the inferior turbinate at the level of the uncinate Forty adult patients with chronic nasal obstruction due to isolated infe- process using coronal planes, and the antero-posterior lengths of the in- rior turbinate hypertrophy, who presented at our outpatient clinic be- ferior turbinate at the level of highest turbinate length using axial planes. tween May 2014 and December 2015, were included in this randomized To calculate the turbinate volumes, we used the formula defined by Sapci prospective study. Patients who did not consent to the surgery with the et al. (2) previously. (Volume=longitudinal length x transverse length x an- follow-up protocol, who had previous nasal surgery and were diagnosed teroposterior length x 0.52) (3). with chronic sinusitis, allergic rhinitis, nasal septum deviation, concha bullosa, nasal polyposis, adenoid vegetation, or pregnancy were excluded To evaluate the nasal resistance, we performed rhinomanometry from the study. pre-operatively and post-operatively (during the 12th and 24th weeks). We encouraged all the patients to point out their level of nasal obstruc- All patients included in the study received pharmacologic therapy for at tion using a VAS pre-operatively and post-operatively (during the 12th least 3 months before the surgery, however, the responses were not sat- and 24th weeks). Moreover, to assess the activity of the nasal mucociliary isfactory. The patients were informed about the surgical procedure and system, we performed the saccharine test pre-operatively and post-op- informed consents were obtained. Patients were randomly and equally eratively (during the 12th and 24th weeks). The study was approved by divided into two groups. Endoscopy-assisted RFTA was performed on an- the local ethics committee of Necmettin Erbakan University (IRB num- terior, medial, and posterior parts of the inferior turbinate by inserting the ber: 2014-54). concha probe (Model number 1120, Gyrus ENT, UK) submucosally and longitudinally in group 1. Every single point of the inferior turbinates re- Statistical Analysis ceived 350 joules of energy (total 1050 joules for an inferior turbinate) with Results are presented as mean + standard deviation. Statistical compar- a target temperature of 75°C. The probe resistance was between 200-300 isons were performed using the Student’s t-test, the Friedman test, and ohms during the energy intake. MD SMR was performed in group 2, using the Wilcoxon signed-rank test. The Statistical Package for Social Sciences a 2 mm flat-tipped microdebrider (Medtronic’s Xomed, FL, USA) at 5000 version 20.0 software for Windows (IBM Corp.; Armonk, NY, USA) was used rpm. After a 3 mm incision was made on the anterior-inferior surface of to perform all the data analyzes. A p-value of less than 0.05 was consid- the inferior turbinate, the submucosal tissues over the bone component ered statistically significant. of the inferior turbinates were shaved. At the end of the surgery, the out fracture was performed on each group. Surgeries were performed under RESULTS local anesthesia with intravenous sedation. Nasal packing was not used on either group. Peroral antibiotic, analgesic, and intranasal saline solution Group 1 consisted of 12 males and eight females (mean age: were prescribed. During the post-operative 1st and 4th week, intranasal en- 32.55±10.96 years), while group 2 consisted of 12 males and eight fe- doscopic examination and cleaning were performed. males (mean age: 33.80±10.28 years). Mean inferior turbinate volumes for each group are shown in Figure 5. Post-operative (24th week) mean To assess the sizes of the inferior turbinates, patients from both groups inferior turbinate volumes were significantly lower than pre-operative underwent a paranasal MRI pre-operatively (Figure 1, 2) and post-oper- mean inferior turbinate volumes in both groups (p<0.001). In addition,

a b

Figure 1. a, b. Preopereative coronal MRI in MSMR group (a), Preopereative axial MRI in MSMR group (b) MRI: magnetic resonance imaging; MSMR: microdebrider submucosal resection Eur J Rhinol Allergy 2019; 2(2): 51-6 Gül et al. Comparison of Radiofrequency and Microdebrider 53

post-operative (24th week) mean turbinate volumes were significantly significantly lower in both groups (p<0.001). Moreover, the mean nasal lower in group 2 as compared to group 1 (p<0.001), while the pre-oper- resistance measured in the post-operative 24th week was significantly ative turbinate volumes did not significantly differ between the groups lower than the values measured in the post-operative 12th week in both (p=0.613). groups (p<0.05; p=0.006 for group 1 and p=0.002 for group 2). The mean pre-operative nasal resistance was not significantly different between the Pre-operative and post-operative mean nasal resistance values for each groups, but the mean nasal resistances measured in the post-operative group are presented in Figure 6. As compared to the pre-operative values, 12th and 24th weeks were significantly lower in group 2 as compared to the mean nasal resistance measured in the post-operative 12th week was group 1 (p<0.001).

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Figure 2. a, b. Preopereative coronal MRI in RFTA group (a), Preopereative axial MRI in RFTA group (b) MRI: magnetic resonance imaging; RFTA: radiofrequency thermal ablation

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Figure 3. a, b. Postopereative coronal MRI in MSMR group (a), Postopereative axial MRI in MSMR group (b) MRI: magnetic resonance imaging; MSMR: microdebrider submucosal resection 54 Gül et al. Comparison of Radiofrequency and Microdebrider Eur J Rhinol Allergy 2019; 2(2): 51-6

Pre-operative and post-operative mean VAS scores and mean mucociliary clearance times for each group are shown on Figure 7 and 8, respectively.

Compared with the pre-operative values, the mean VAS scores for nasal obstruction level measured in the post-operative 12th and 24th weeks were significantly lower in both groups (p<0.001). Moreover, the post-operative values during the 12th and 24th weeks VAS scores were significantly lower in group 2 as compared to the group 1 (p<0.001) (Figure 7).

Mucociliary clearance times measured pre-operatively and post-operatively (during the 12th and 24th week) did not differ significantly between the groups (p=0.565 and p=0.488, respectively) (Figure 8).

Figure 5. Preoperative and postoperative mean inferior turbinate volumes on MRI for RFTA and MSMR groups (mm3) MRI: magnetic resonance imaging; RFTA: radiofrequency thermal ablation; MSMR: microdebrider submucosal resection

Figure 6. Preoperative and postoperative mean nasal resistance for RFTA and MSMR groups (Pa/cm3/sec) RFTA: radiofrequency thermal ablation; MSMR: microdebrider submucosal resection b

Figure 7. Preoperative and postoperative mean VAS scores for RFTA Figure 4. a, b. Postopereative coronal MRI in RFTA group (a), and MSMR groups Postopereative axial MRI in RFTA group (b) VAS: visual analog scale; RFTA: radiofrequency thermal ablation; MSMR: MRI: magnetic resonance imaging; RFTA: radiofrequency thermal ablation microdebrider submucosal resection Eur J Rhinol Allergy 2019; 2(2): 51-6 Gül et al. Comparison of Radiofrequency and Microdebrider 55

it is instrumental in displaying the nasal mucosal structures (18). For this reason, MRI can be used as a reference imaging method to evaluate the results of the studies on turbinate surgery.

Peak nasal inspiratory flow meter, odiosoft-rhino, acoustic rhinometry, and rhinomanometry can be used as effective laboratory methods to evaluate nasal function and assess the efficacy of the procedure in surgically treated patients objectively.

Saccharine clearance test, a noninvasive and easily applicable method, is commonly used to assess mucociliary clearance system in otolaryngology practice (13).

In this study, we compared the effectiveness and reliability of radiofrequency thermal ablation versus microdebrider submucosal resection techniques for the treatment of isolated inferior turbinate hypertrophy. Figure 8. Preoperative and postoperative mean mucociliary clearance Rhinomanometry and MRI were the preferred laboratory techniques. Na- times for RFTA and MSMR groups (min) sal mucosal clearance was assessed with the saccharine test. Furthermore, RFTA: radiofrequency thermal ablation; MSMR: microdebrider submucosal resection; min: minute VAS scores were also evaluated.

DISCUSSION A prospective study in literature collated the results of a turbinoplasty, which was performed either through radiofrequency or a microdebrider. Inferior turbinate hypertrophy frequently causes nasal obstruction (3). In both groups, a 4-point scale was used, and the severity of several symp- Physicians have many surgical treatment options for inferior turbinate hy- toms (nasal obstruction, nasal drip, headache, and hyposmia) were ana- pertrophy, which are recalcitrant to medical treatment. Due to the fact lyzed. Moreover, both groups were subjected to a rhinomanometry test that surgical intervention can affect mucociliary function, the integrity of pre-operatively and in the 3rd month. Upon the evaluation of the results, nasal mucosa should be minimally damaged during the surgery (4). it was reported that both techniques are individually effective and have similar rates of complications. Long-term and short-term results were A study on the assessment of inferior turbinate surgery results revealed compared between the patient groups, and the results of the turbino- that physicians usually prefer MSMR or RFTA turbinoplasty for the treat- plasty that was performed through the microdebrider were better (7). ment of inferior turbinate hypertrophy. Both the surgical techniques pre- Another study in the literature compared the RFTA and MSMR methods serve nasal physiology without creating any histopathologic changes in in patients with inferior turbinate hypertrophy, and any statistical signifi- mucosa and do not lead any major complications (5-8). cance in the saccharine clearance between the two methods could not be detected (19). Cavaliere et al. (9) reported that RFTA is a surgical method, which reduces the volume of the inferior turbinate without any remarkable injury of the In this study, post-operative (during the 24th week) mean inferior turbi- nasal mucosa and without any inconvenience of the patient (10). Accord- nate volumes on the MRI were significantly lower than the pre-operative ing to previous investigations, RFTA minimally affects the nasal mucosal mean inferior turbinate volumes in both groups. In addition, while the physiology (2, 11-13). In a study with 21 patients who were treated by pre-operative turbinate volumes were not significantly different between RFTA, the pre- and post-operative average turbinate volumes were com- the groups, the post-operative mean turbinate volumes were significantly pared by MRI and the statistically significant difference was reported (2). In lower in the MSMR group as compared to the RFTA group. The mean nasal the other study, Civelek et al. (14) compared the total resistance values of resistance measured in the post-operative 12th and 24th week were sig- the nasal cavities pre- and post-operatively as part of RFTA technique and nificantly lower as compared to the pre-operative values in both groups. determined a statistically significant difference (14). In a study focused on While the mean pre-operative nasal resistance was not significantly dif- the effects of the partial turbinectomy via a laser surgery and RFTA on the ferent between the groups, the mean nasal resistances measured in the mucociliary transport system, the patients who had undergone RFTA had post-operative 12th and 24th week were significantly lower in in MSMR the highest mucociliary transport rates, similar to the control group (2). group as compared to RFTA group.

Microdebrider submucosal resection (MSMR) of inferior turbinate is a sur- The post-operative 12th and 24th week VAS scores for the nasal obstruc- gical method with reasonable morbidity rates that’s preserves the integri- tion level were significantly lower in the MD SMR group as compared to ty of the inferior turbinate and does not damage the nasal mucosa. It pro- RFTA group. Like previous publications based on saccharine clearance test vides a controlled resection of the turbinate. Preservation of the mucosa (19), our study suggests that both the RFTA and MSMR does not affect results in maintenance of the mucociliary function and reduces the risk the mucociliary clearance system. Mucociliary clearance times measured of complications (15). Mucosal tears are frequently observed as compli- pre-operatively and post-operatively (in the 12th and 24th week) did not cation during the operation (16). The tears are generally seen on a limited significantly differ between the groups. area, especially on the medial surface of the concha. Mucosal integrity is protected in this case (17). In our study, no patients had any particular intra-operative or post-operative hemorrhage, therefore, the complication of hemorrhage is unremark- Magnetic resonance imaging (MRI) is a radiological examination in which able for both RFTA and MSMR. Four patients who underwent MD SMR had the patient does not experience any side effect. Although MRI has a lim- minimal tears on the medial surface of the unilateral concha, but synechia ited role in rhinology because of poor visualization of the bone tissue, was not detected in the post-operative control group. 56 Gül et al. Comparison of Radiofrequency and Microdebrider Eur J Rhinol Allergy 2019; 2(2): 51-6

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