Comparison of the Effects of Radiofrequency Tissue Ablation, CO 2 Laser Ablation, and Partial Turbinectomy Applications on Nasal Mucociliary Functions

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1 The Laryngoscope Lippincott Williams & Wilkins, Inc., Philadelphia 2003 The American Laryngological, Rhinological and Otological Society, Inc. Comparison of the Effects of Radiofrequency Tissue Ablation, CO 2 Laser Ablation, and Partial Turbinectomy Applications on Nasal Mucociliary Functions Tarik Şapçi, MD; Betül Şahin, MD; Ahmet Karavus, MD; Uğur Günter Akbulut, MD Objectives: One of the major causes of chronic nasal airway obstruction is disease of the inferior turbinate. However, there is no agreement on how to deal with this problem. Comparison was made of the nasal functions after treatment by radiofrequency tissue ablation, laser ablation, and partial turbinectomy using subjective symptom scores and objective tests. Study Design: Prospective, randomized clinical trial. Methods: The study was conducted on three groups of 45 adult volunteer patients with symptoms and signs of nasal obstruction and stuffiness related to enlarged turbinates. In group A, laser ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group B, radiofrequency tissue ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group C, patients who were not treated by any surgical techniques were the control subjects. Clinical examinations, visual analogue scales, rhinomanometry, and isotopic study of nasal mucociliary transport time were used to assess treatment outcomes. Results: At 12 weeks after surgery, the nasal mucociliary transport time results were compared in the same patients. The average time was minutes on the side where laser ablation was applied and minutes on the side where partial turbinectomy (FT) was applied. In the patients on whom radiofrequency tissue ablation and partial turbinectomy were applied, the average nasal mucociliary transport time was minutes on the radiofrequency tissue ablation side, whereas it was minutes on the partial turbinectomy side. Rhinomanometric measurements demonstrated a significant decrease in nasal resistances at 12 weeks in both sides in groups A and B. Conclusions: In the study it was demonstrated that radiofrequency tissue ablation to the turbinate is ef- From the Department of Otorhinolaryngology Head and Neck Surgery. Posta Telefon Telgraf Training Hospital, Istanbul, Turkey. Editor's Note: This Manuscript was accepted for publication October Send Correspondence to Tarik Sapci, MD, Gozenc sok. 14/9, Erenkoy-Istanbul, Turkey. tariksapci@turk.net 514 fective in improving nasal obstruction objectively and in preserving nasal mucociliary function. Laser ablation of the turbinate is effective in improving the nasal obstruction; however, it disturbs the mucociliary function significantly. With the partial turbinectomy technique, results obtained were similar to the results with the radiofrequency tissue ablation technique. Key Words: Radiofrequency, laser, partial turbinectomy, nasal obstruction, turbinate hypertrophy, subjective and objective parameters. Laryngoscope, 113: , 2003 INTRODUCTION Nasal obstruction is one of the oldest and most common human complaints. Hypertrophy of the inferior turbinate is a common cause of chronic nasal obstruction. No agreement has been reached on how to deal with this problem. A number of interventions are available for the treatment of nasal obstruction secondary to inferior turbinate hypertrophy, including immunotherapy, antihistamines, intranasal corticosteroid sprays, decongestants, corticosteroid turbinate injections, cryosurgery, electrocautery, out-fracture, total or partial turbinectomy, turbinoplasty, submucous resection, laser-assisted turbinoplasty, and radiofrequency energy tissue ablation. 1 " 3 An ideal procedure for turbinate reduction should be associated with minimal discomfort or adverse reactions and should preserve the physiological function of the turbinate, such as regulating the humidification and temperature of the inspired air. 4 All of the techniques have potential complications that fall into several categories. 5 The main goal of turbinate surgery should be the preservation of mucosal surfaces with reduction of the submucosal tissue. No technique is perfect, and each is associated with known short- and long-term complications such as bleeding and atrophic rhinitis. 0 The variety of surgical techniques available indicates the lack of consensus on the optimal technique. Mucociliary function is an important defense mechanism that protects the respiratory system against bacteria

2 and other foreign particles. Nasal mucociliary function is impaired in the majority of surgical reductions of the inferior turbinate. 6 A wider nasal cavity does not necessarily mean the nose functions better. The goal of the surgical treatment should be to diminish complaints while preserving function and optimal volume reduction together with preservation of function. 7 In the present study, we used both subjective symptoms and objective tests to assess the efficacy of radiofrequency energy, CO 2 laser, and partial turbinectomy in treatment of nasal obstruction attributable to inferior turbinate hypertrophy. MATERIAL AND METHODS Study Design A prospective randomized clinical study was conducted on three groups of 45 adult volunteer patients who were chosen from 68 patients receiving follow-up care in our clinic with a diagnosis of turbinate hypertrophy. All of these 45 patients had symptoms and signs of nasal obstruction and stuffiness related to enlarged turbinates and were treated between August 1998 and January All patients gave their written informed consent before being included in the study, which was approved by the Ethics Committee. All procedures were performed by one author (T.S.). Patients Patients with previous turbinate surgery, septal deformities, nasal polyps or tumor, nasal radiotherapy, or recurrent sinusitis were excluded. Additional exclusion criteria included diabetes mellitus, oral steroid use, coagulation disorder, cardiac pacemaker, and uncontrolled hypertension. Furthermore, patients who had a genetic disorder accompanied by ciliary dysfunction, those using a topical or systemic medication having adverse effects on mucociliary function, and also smokers were excluded from the study. Examination included anterior rhinoscopy and nasal endoscopy in all patients. Patients had been treated previously with topical corticosteroids, antihistamines, decongestants, and topical anticholinergic agents. Patients whose complaints had subsided partially or not at all were admitted to the study. Furthermore, patients who were selected to receive surgery had smaller inferior turbinates after the nasal application of topical vasoconstrictive agents. Forty-five patients were randomly assigned into three groups (groups A, B, and C) of 15 patients each (the patients were chosen to be put into a particular group simply by drawing lots). In group A, laser ablation (LA) was applied to the inferior turbinate on one side and partial turbinectomy (PT) to the inferior turbinate on the other side. In group B, radiofrequency tissue ablation (RFTA) was applied to the inferior turbinate on one side and partial turbinectomy (PT) to the inferior turbinate on the other side. Group C patients, who were not treated with any surgical techniques, served as control subjects. None of the patients was excluded from the study, and all patients completed treatment. The same surgeon performed all the surgical procedures. Of the group A patients, 11 were female and 4 were male patients. The mean patient age was 25.6 years (±6.4 y standard deviation [SD]). The surgical interventions were carried out with the patient under local anesthesia. Partial turbinectomy was applied to the randomly selected side of the patients (either left or right side) on the inferior turbinate. (The choice of which of the turbinates was to be treated was made by the investigator. The side of the application was changed at each consecutive application [e.g., if LA was performed on the left side and PT on the right side in first patient, LA was performed on the right side in the second patient, and so forth].) To perform PT, the inferior onethird of the inferior turbinate was squeezed with a Kelly forceps, and after 10 seconds the forceps was rotated clockwise, while CO 2 laser (30 W) (Sharplan 1020, Sharplan Laser Industries, Tel Aviv, Israel) was applied to the inferior turbinate of the other side. The CO 2 laser with optical wave-guide was operated with the power setting of 8 to 10 W, using both focused and defocused beams. A continuous superpulse mode was preferred, to avoid excessive tissue damage. The inferior turbinate was ablated medially and inferiorly under endoscopic guidance. After the operation a nasal pack was applied on the side with PT for 48 hours; however, no nasal pack was applied at all on the other side with LA. Antibiotic therapy with amoxicillin and analgesia with acetaminophen were given for 5 days postoperatively. Of the group B patients, seven were male and eight were female patients. The mean patient age was 26.1 years (±7.1 y SD). The interventions were carried out with the patient under local anesthesia. Partial turbinectomy was applied to the randomly selected side of the patients (either left or right) on the inferior turbinate (the side of the application was changed at each consecutive application), and RFTA (Surgitron, Ellman International, Inc., Hewlett, NY) was applied on the inferior turbinate of the other side. No vasoconstrictive agent was used topically or by injection, to avoid turbinate shrinkage, which was thought to increase the risk of potential mucosal injury and postoperative complications. The radiofrequency electrode was inserted submucosally under endoscopic guidance, and the energy was delivered to three different sites of each turbinate (to the anterior, middle, and posterior portions). Radiofrequency energy used in the present study was 10 to 15 W, for 15 seconds. In small turbinate, two applications were made to the anterior and posterior parts. Also, energy delivery was stopped, once whitening was established on the applied region of the mucosa (power was held constant while time was decreased). Antibiotic therapy with amoxicillin and analgesia with acetaminophen were given for 5 days postoperatively. Group C was the control group, being made up of 6 male and 9 female patients; the mean age of the patients was 23.6 years (±8.4 y SD). These patients declared that they had been receiving medical treatment for 12 weeks for their complaints but that these had not diminished. No surgical operation was carried out in these control patients. Evaluation Subjective symptoms including severity of nasal obstruction were measured by a standard 10-cm visual analogue scale (VAS). The patient's assessment of the degree of nasal obstruction was recorded. A score of 0 represented no obstruction and no episodes of nasal obstruction, and a score of 10 indicated complete nasal obstruction and constant, unremitting nasal obstruction. Rhinomanometric measurements of the patients in groups A and B were made before and on the 12th week after the operation. Anterior active positional rhinomanometry was performed with a Rhinotest MP 500 rhinometer (Brehm and Jung Electronic, Darmstadt, Germany), and the total nasal resistance at 150 Pa was used for comparison. 8 No decongestion was performed to the turbinates during measurements before or after the operation. The mucociliary function of patients in groups A and B was evaluated using a radioisotope with a half-life of 7 days at 10-day intervals after the end of the third postoperative month. The mucociliary function of the inferior turbinate of one side in the group C patients was evaluated 1 month after the medical treatment was completed. In all patients, nasal mucociliary transport was evaluated using the radioisotopic technique with serum albumin labeled 515

3 with technetitnn 99m (Tc-99m). The albumin macroaggregate used as a tracer in the present study had a diameter of 10 to 60 fim. The amount of substance applied was 0.01 ml, with a weight of g and a radioactivity of 25 /xci. The detection system employed consisted of a gamma camera. The tracer was placed on the anteromedial aspect of the head of the inferior turbinate. The test was ended when the tracer reached the nasopharynx. The subject was positioned lying face-up on the gamma camera, with the head turned to rest the trial nasal fossa on the detector. The gamma camera was linked to a computer programmed to take dynamic images (128 X 128 pixels) at the rate of one image per minute, for a total of 10 images, which were computer processed, considering the following parameters: position of tracer in the first minute, position of the tracer in the last minute, and transport time. The tests were performed under regulated temperature and humidity in a conditioned room with hygrometric control (temperature, C; relative humidity, 57%-67%). Statistical Analysis Statistical analysis was performed by a specialized company using the statistical software package SPSS for Windows, version 9.0. Student t test and Wilcoxon signed rank test were used, and a P value of less than.05 was considered to be statistically significant. RESULTS Forty-five patients (28 women, 17 men) were enrolled in the present study. None of the patients had a history of allergy. The results of skin-prick test, nasal smears, and radioallergosorbent test for specific allergens were all negative for all the patients. All patients had a diagnosis of vasomotor dysfunction. In group A patients, no hemorrhage requiring nasal pack was observed on the side where LA was performed. During the postoperative period, slight crusts were observed in four of the patients, and these completely healed afterward. On the side where PT was performed, no uncontrolled bleeding was observed during the operation. In fact, coagulation with cautery was not needed at all during the operation; a nasal pack was applied in all patients and retained for 48 hours. After the nasal pack was removed in three patients, slight bleeding, which could be controlled easily, occurred. During the postoperative period, thick crusts were observed in eight of the patients. These crusts disappeared after close follow-up. No formation of synechiae developed. In group B, no postoperative bleeding was observed, and no nasal pack was required on the side where RFTA was applied; besides, no crusts developed. All of the patients healed with no problems except for slight swelling of the inferior turbinate, which occurred in the first 1 or 2 days. On the side where PT was applied, no uncontrolled bleeding was observed during the operation; in fact, coagulation with cautery was not needed at all. Nasal packs were applied in all patients and were retained for 48 hours. Dense crusts developed in seven patients after the operation, but they healed completely. Formation of synechiae developed in one patient, who needed to be cured by opening the synechiae; there was no recurrence later, during the follow-up period. slightly worsened during the first 4 or 5 days and began to improve in the first postoperative week. Statistically significant improvement was observed at 12 weeks after treatment in all patients (P <.001). The severity of nasal obstruction after RFTA began to improve significantly from the fourth day after treatment, and this improvement continued to 6 to 8 weeks after the operation. Statistically significant improvement was observed at 12 weeks after treatment in all patients (P <.001) (Fig. 1). Rhinomanometry Rhinomanometric measurements demonstrated a significant nasal resistance decrease at 12 weeks on both sides in groups A and B (Table I). Nasal Mucociliary Transport Time Nasal mucociliary transport time in the control group (group C) varied between 7 and 17 minutes, with a mean value of minutes (± 8.07 min SD) (Table II). When the NMTT of group A patients was measured, an average NMTT of minutes (±5.90 min SD) was observed on the side where LA was carried out, and an average NMTT of minutes (±1,99 min SD) was observed on the side where PT was performed. The statistical difference was found to be high between the mean NMTT values (P <.001) (Table III). When the NMTT of the group B patients was measured (on average, min [±1.84 min SD] on the side where RFTA was performed and min [±2.09 min SD] on the side where PT was performed), the difference was observed as being not statistically significant (P >.O5) (Table IV). DISCUSSION The successful use of different lasers to reduce hyperplastic nasal turbinates has been reported in clinical studies. 9 " 15 Lasers have been introduced into surgery for the management of turbinate hypertrophy, usually as a tool for resection of the inferior turbinate. 16 The C0 2 laser Subjective Change of Symptoms With regard to patient-assessed VAS, in the inferior turbinate treated with LA or PT the subjective symptoms 516 Sapci et al.: Nasal Mucociliary Functions

4 with wave-guide directly ablates the turbinate mucosa and glandular tissue using the superpulse mode. 16 Lasers produce a beam of coherent light that is absorbed by the tissues; the extent of absorption depends on its wavelength. The energy thereby released evaporates the tissue. The depth of the lesion thus created depends on the wavelength, the extent of tissue absorption, and the amount of energy applied. Its diameter depends on the spot size of the laser beam. Thus, laser technology can be used in different ways depending on the parameters used. One of the parameters is the mode of application, either continuous or pulsed. Most authors have used pulsed laser treatment because a continuous laser beam causes damage in a wider area. With the superior properties that laser is a minimally invasive method, the patient has relatively more comfort, and the secretion and congestion ability of the turbinate is decreased because of the atrophy of seromucinous glands and vascular structures it has caused, laser surgery of the turbinates does not meet the requirement of optimal volume reduction in combination with Şapci et al.: Nasal Mucociliary Functions 517

5 preservation of function. If a limited amount of mucosa and submucosa is evaporated, the volume reduction is probably insufficient. If the mucosal volume is sufficiently reduced, the functional damage will be severe and irreversible. 7 However, the laser beam narrows the turbinates effectively and is comfortable for the patient both during and after the operation. Some of the authorities have not recommended it because of its adverse effects on mucociliary function as a late complication. According to Hoi and Huizing, 7 laser surgery is not compatible with modern concepts of functional nasal surgery and should not be used to treat a hypertrophic inferior turbinate. Radiofrequency tissue reduction is a surgical procedure that uses radiofrequency heating to induce submucosal tissue destruction, leading to the reduction of tissue volume. 4 This energy induces ion agitation within the tissue, which increases the local temperature and causes a thermal lesion that should occur in the deep mucosa without damaging the surface. The healing process secondarily induces fibrosis with wound contraction, leading to tissue volume reduction. Therefore, radiofrequency could be useful for turbinate volume reduction because, theoretically, it should help to treat nasal obstruction without the disadvantages of the other techniques. 17 Recently, radiofrequency energy has been used for the treatment of the hypertrophied turbinate. 1,3,18 In studies on RFTA of the turbinate, improvement of severity and frequency of nasal obstruction were reported in 81% to 100% of cases. 1, 4 However, we still should be prudent in using this practical technique because it is new and we do not yet have much knowledge about the long-term results. Although most of the surgical techniques are successful in improving respiration, most of them do not take the functions into consideration. In recent years, laser and radiofrequency have become popular, with many reports of their effectiveness and of their adverse effects. In our clinic, we are using both techniques. In the present study, we compared both of these techniques with the conventional operation called PT. Our comparison particularly aimed at comparing their effects on mucociliary function. In the present study, the RFTA, LA, and PT techniques all proved to give objectively and subjectively successful results as far as the respiratory functions were concerned. However, this was not true for their effects on mucociliary functions. In the present study, when the preoperative and postoperative respiratory functions of patients in groups A and B were compared, statistically significant improvements were observed. Apparent improvement in rhinomanometric measurements of the LA and PT patients was detected at the 12th postoperative week. When the NMTT results were compared in the same patients, the average NMTT was minutes on the side where LA was applied and minutes on the side where PA was applied. Furthermore, the average NMTT was measured as minutes in the control group. This long NMTT on the side where LA was performed could be explained by the damage of the entire mucosa on the transport route of the tracer because of the complete vaporization of the medial and inferior sides of the inferior turbinate by laser. The prolonged NMTT on the LA sites as compared with the PT sites and 518 the control group in the 12th week after the operation may be a sign of the irreversible impairment that the CO 2 laser may have caused on the nasal mucosa. Similar interpretations can be found in the literature. Elwany and Abdel- Moneim 19 have observed the following mucosal findings on biopsy of patients 1 month after CO 2 laser turbinectomy: early epithelial loss that was followed by prompt regeneration of healthy epithelium, decreased number and activity of the seromucinous glands, fibrosis of the connective tissue stroma, and diminished number and congestion of the cavernous blood spaces. Passali et al. 20 demonstrated that laser cautery of the turbinates might induce long-term impairment of mucociliary transport time. Wexler et al. 21 determined permanent histopathological soft tissue changes in their laser turbinectomy patients. Aside from the negative effects of laser on the mucociliary function, there may also be problems in performing it. According to our experience, C0 2 laser technique took the longest time of application. We preferred the continuous mode to shorten the application time. We find it difficult to perform vaporization on a wide mucosal area with a single mode, although there have been opinions in the literature that continuous-mode applications on a wider area may cause tissue damage. Aside from the prolonged application time, the difficulty in working on the posterior of the turbinate and small burns caused by exposure of the surrounding tissue to the projection of the ray were our most important problems. In the patients on whom RFTA and PT were applied, the average NMTT was minutes on the side where RFTA was applied, whereas it was minutes on the side where PT was applied. The shortness of NMTT and also closeness to the control group may indicate that RFTA causes no apparent functional loss on the nasal mucosa. Our study evaluates the results at the 12th postoperative week. In a study that examined earlier mucosal changes, Coste et al. 17 showed for the first time that even at 1 week after the procedure, ciliated cells were still present in the surface epithelium, exhibited a normal ciliary beat frequency, and were able to ensure effective mucociliary clearance as evaluated by the saccharine transit time results. Rhee et al. 22 demonstrated that mucociliary transport time did not show a significant difference after radiofrequency tissue ablation. Another study, which evaluated the late nasal mucosal effects of radiofrequency, reported that transmission electron microscopy performed 1 year postoperatively showed that the epithelium was intact with ciliated and goblet cells. 18 One should be careful about certain points with RFTA, which is extremely easy to perform. It is especially important that the performer examine the mucosa of the turbinate while calibrating the amount of energy to give. In situations in which the electrode cannot not be placed properly in the submucosal area or the turbinates are small, one should not be bound to the standard energy Application criteria. The procedure must be stopped once a mucosal whitening occurs; otherwise, a mucosal necrosis may develop. We were surprised that the NMTT was not greatly prolonged despite the mucosal damage in the patients in

6 whom PT was performed. However, we think that in the technique we have used, the resection of only the inferior one-third of the turbinate, no cauterization or use of other applications likewise after the resection, and the application of the tracer (used in the NMTT measurement) on the anteromedial region (the undamaged region) caused this result. CONCLUSION In evaluating the various methods of turbinate reduction, above all, we must consider the function of the turbinates. Then we will have to define the criteria that a given surgical method must meet to be considered acceptable. All methods should be judged by two basic criteria: the efficacy of the technique in alleviating breathing obstruction and the side effects occurring in the short and the long term. In the present study, we demonstrated that RFTA and PT are effective in improving nasal obstruction objectively and in preserving nasal mucociliary function. Our study was based on a limited sample size and a relatively short follow-up period. Therefore, further follow-up study is needed for evaluation of long-term improvement of symptoms and maintenance of nasal function. BIBLIOGRAPHY 1. Utley DS, Goode RL, Hakim I. Radiofrequency energy tissue ablation for the treatment of nasal obstruction secondary to turbinate hypertrophy. Laryngoscope 1999; 109: Jackson LE, Koch RJ. Controversies in the management of inferior turbinate hypertrophy: a comprehensive review. Plast Reconstr Surg 1999;103: Smith TL, Correa AJ, Kuo T, Reinisch L. Radiofrequency tissue ablation of the inferior turbinates using a thermocouple feedback electrode. Laryngoscope 1999;109: Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Radiofrequency volumetric tissue reduction for treatment of turbinate hypertrophy: a pilot study. Otolaryngol Head Neck Surg. 1998;119: Dawes PJ. The early complications of inferior turbinectomy. JLary-ngol Otol 1987;101: Nuutinen J. Asymmetry in the nasal mucociliary transport rate. Laryngoscope 1996;106: Hoi MKS, Huizing EH. Treatment of inferior turbinate pathology: a review and critical evaluation of the different techniques. Rhinology 2000;38: Gordon AD. Rhinomanometry for preoperative and postoperative assessment of nasal obstruction. Otolaryngol Head Neck Surg 1989;101: Oswal V, Bingham B. A pilot study of the Holmium:YAG laser in nasal turbinate and tonsil surgery. J Clin Las Med Surg 1992;10: Kautzky M, Bigenzahn W, Steurer M, Susani M, Schenk P. Use of the Holmium:YAG laser in functional endoscopic endonasal surgery. HNO 1992;40: Kawamura S, Fukutake T, Kubo N, Yamashita T, Kumazawa T. Subjective results of laser surgery for allergic rhinitis. Ada Otolaryngol Suppl (Stockh) 1993;500: Lippert B, Werner J. CO 2 laser surgery of hypertrophied inferior turbinates. Rhinology 1997;35: Levine H. Endoscopy and the KTP/532 laser for nasal sinus disease. Ann Otol Rhinol Laryngol 1989;98: Lippert B, Werner J. Treatment of the hyperplastic inferior turbinates. Laryngol Rhinol Otol 1996;75: Dilkes M, Cameron I, Quinn S, Kenyon G. Preliminary experience with an 810 nm wavelength diode laser in ENT surgery. Laser Med Sci 1994;9: Krespi YP, Keidar A. Laser-assisted uvulopalatoplasty for the treatment of snoring. Operative Techn Otolaryngol Head Neck Surg 1994;5: Coste A, Yona L, Blumen M, et al. Radiofrequency is a safe and effective treatment of turbinate hypertrophy. Larvngoscope 2001;lll: Elwany S, Gaimaee R, Fattah HA. Radiofrequency bipolar submucosal diathermy of the inferior turbinates. Am J Rhinol 1999;13: Elwany S, Abdel-Moneim MH. Carbon dioxide laser turbinectomy: an electron microscopic study. Ada Otorhinolaryngol Ital 1995;15: Passali D, Lauriello M, Anselmi M, Bellussi L. Treatment of hypertrophy of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy. Ann Otol Rhinol Laryngol 1999;108: Wexler DB, Berger G, DeRowe A, Ophir D. Long-term histologic effects of inferior turbinate laser surgery. Otolaryngol Head Neck Surg 2001;124: Rhee CS, Kim DY, Won TB, et al. Changes of nasal function after temperature-controlled radiofrequency tissue volume reduction for the turbinate. Laryngoscope 2001;lll: