Microdebrider-assisted turbinoplasty Versus submucosal cauterization in Inferior turbinate hypertrophy Protocol submitted for the partial fulfillment of the M.D degree in Otorhinolaryngology By Abdel Rahman Younes Ali (M.B.B.Ch / M.Sc. E.N.T. Cairo University) Under Supervision of Prof. Dr. Mohamed Sadek Rifai Professor of Otorhinolaryngology Cairo University Prof. Dr. Mohamed Salah El-Din Hassouna Professor of Otorhinolaryngology Cairo University Prof. Dr. Hady Salah El-Din AbdelAzim Professor of Otorhinolaryngology Cairo University Faculty of Medicine Cairo University 2012
Abstract Chronic nasal obstruction is one of the most common human problems and a very frequent symptom in the ear, nose, and throat field. Hypertrophy of the inferior turbinates is the most frequent cause and may be related to allergy, pseudo allergy, nonallergic rhinitis with eosinophilic syndrome, and iatrogenic rhinopathy. Even though medical treatments are frequently effective to restore comfortable nasal breathing, nasal obstruction is sometimes slightly improved, leading some patients to increase their consumption of local decongestants with a high risk of iatrogenic effects. In these cases, surgical reduction of inferior turbinates can be proposed. Inferior turbinate surgery is advocated for relief of symptoms in patients with chronic nasal congestion. Numerous reports substantiate the usefulness of inferior turbinate surgery. Mucociliary function is an important defense mechanism that protects the respiratory system against bacteria and other foreign particles. Nasal mucociliary function is impaired in the majority of surgical reductions of the inferior turbinate. A wider nasal cavity does not necessarily mean that the nose functions are better. The goal of the surgical treatment should be to diminish complaints while preserving functions and optimal volume reduction together. A large variety of surgical procedures have been described, each with its own advantages and imperfections. Any technique destroying the turbinate mucosa (surface electrocautery, cryosurgery, total turbinectomy) is more likely to lead to a loss of turbinate function, crusting, and adhesions.
Some techniques of submucosal tissue reduction (SMC, injection of steroids or sclerosing agents) can preserve turbinate function but are generally found to offer only a limited or short-term result. A tailored resection of submucosal soft tissues _ turbinate bone (turbinoplasty) has been reported to provide the best long-term results in a large prospective comparative trial by Passali et al (Passali et al, 2003). During the last decade, a number of techniques for turbinoplasty have been described. Since it was first reported by Davis and Nishioka, most authors prefer powered instruments (Davis & Nishioka, 1996) and visualization by rigid endoscope. The extent of resection includes bone, submucosa, and lateral/inferior mucosa in most studies ;( Bielamowicz et al, 1999) however, some authors avoid mucosal damage and only resect bone or submucosa. Regardless of these variations, all authors agree that turbinoplasty is a superior technique for the management of inferior turbinate hypertrophy, producing a lasting and adequate decrease in turbinate size with low morbidity. Endoscopic microdebrider assisted inferior turbinoplasty is a newly developed surgical technique. When compared with traditional surgical treatments, endoscopic microdebrider assisted inferior turbinoplasty has the advantages of being minimally invasive, allowing the preservation of physiological nasal mucosa, and being a painless and tolerable procedure that is easily achieved with the patient under local anesthesia in an outpatient clinical setting.
On the other hand, submucosal cauterization (SMC) remains a very popular technique because of its technical ease and lack of complications. Although recent studies preliminarily confirmed the effectiveness of turbinoplasty in relieving nasal obstruction, little is known about the prognostic factors determining the outcome. Theoretically, the allergic status of patients, by affecting the regional inflammatory condition of the nasal mucosa and submucosal tissue, might influence procedures aimed at reducing the volume of the inferior turbinate. Key words; Microdebrider-assisted turbinoplasty Versus submucosal cauterization in Inferior turbinate hypertrophy.
Acknowledgement First and foremost thanks to ALLAH, the most beneficient and merciful. I would like to express my appreciation, deepest gratitude and enoromous to prof. Dr. Mohamed Rifai. Professor of Otorhinolaryngology, Faculty Of Medicine, Cairo University. Because of his unlimited support, helpful spirit and his own scientific experience, which he devoted to me to do my assay, my thanks to him is endless and so warm. I would like to express my sincere and great gratitude to prof. Dr. Mohamed Salah. professor of Otorhinolaryngology, Faculty Of Medicine, Cairo University. and prof. Dr. Hady Salah. professor of Otorhinolaryngology, Faculty Of Medicine, Cairo University For their continous support, valuable advices and greatest help. I extend my deepest thanks to all my professors and all my colleagues in ENT departement, Faculty of Medicine, Cairo University. for their continous encouragement and support. I am extremely grateful to my family especially my mother for their kindness, toleration, devotion and motivation, without their support and helpfulness, this work would never have come to light. I
List of Contents Contents Page List of tables III List of figures V introduction 1 Aim of work 4 Review of literature 5 Material and methods 68 Results 83 Discussion 105 Conclusion 118 Summary 119 References 121 II
List of Figures Number of figure Title Page 1. Endoscopic view of a normal inferior turbinate (right nasal side) 5 2. Diagram showing the inferior turbinate with its bony part with covering periostium and arterial blood supply 6 3. Inferior turbinate (Coronal section through its anterior part, MG (modified cold) staining. 7 4. Inferior turbinates (coronal section at the posterior part of the nasal cavity; MC (modified cold) staining 8 5. The turbinates (axial section at the level of the cranial part of the middle nasal passage, modified cold MC staining). 9 6. Vestibule and valve area with its various structures 13 7. Nasal valve area 14 8. Placement of pressure tubing for anterior rhinomanometry 25 9. Placement of pressure tubing for posterior rhinomanometry 26 10. Placement of pressure tubing for postnasal (pernasal) rhinomanometry 26 11. Anterior mask rhinomanomerty (Side view) 28 12. Anteroir mask rhinomanometry (front view) 28 13. respiratory cycle on flow and pressure tracings and on the pressure-flow plot 32 14. The pressure-flow curve 33 15. Turbinate Outfracture 51 16. Technique of anterior turbinoplasty according to Pirsig and Huizimg 62 17. Microdebrider-assisted turbinoplasty A, B: Site of insertion of Microdebrider blade 65 C, D: Submucous resection by Microdebrider 66 18. CT evaluation of a patient preoperatively showing bilateral hypertrophied inferior after medical therapy turbinates and 69 excluding other pathologies 19. CT evaluation of a patient after medical treatment showing Bilateral hypertrophied inferior turbinates with very mild 70 deviated nasal septum 20. Endoscopic examination of a patient confirming that hypertrophied inferior turbinate is the main cause of nasal obstruction 72 III
21. 22. 23. Endoscopic view showing insertion of the microdebrider 2mm blade through sub mucosal tunnel. Endoscopic view showing the site of insertion of the micodebrider blade after reduction of the anterior part of the turbinate Endoscopic view during follow up of a patient showing the side where microdebrider turbinoplasty was performed 6 month earlier 24. male to female ratio 83 25. Follow up of nasal obstruction among both groups 95 26. Follow up of nasal discharge among both groups 96 27. Follow up of nasal crustation among both groups 97 28. Comparison between patient (treated by microdebrider) and patient (treated by SMD) as regard postoperative patient satisfaction 79 80 81 98 IV
List of Tables Number of table 1. Title Different modalities of treatment for inferior turbinate hypertrophy Page 2. Four-point scale of nasal obstruction(cingi et al.,2010) 74 3. Four-point scale of nasal discharge(cingi et al.,2010) 75 4. Four-point scale of nasal crustations(cingi et al.,2010) 75 43 5. 6. 7. 8. 9. 10. 11. 12. 13. Four-point scale of patient s satisfaction (Cingi et al.,2010) Comparison between right side (treated by microdebrider ) and left side (treated by Submucous diathermy SMD) as regard preoperative data Comparison between group A&B as regard operative duration Mean time between the operation and apparent healing of both group A& B The difference between mean of total nasal resistance measured by rhinomanometry pre and postoperative Comparison between right side (treated by microdebrider) and left side (Submucous diathermy SMD) as regard postoperative data (7days) Comparison between right side (treated by microdebrder) and left side (treated by Submucous diathermy SMD) as regard postoperative data (1month) Comparison between right side (treated by microdebrider )and left side (treated by SMD) as regard postoperative data (3month) Comparison between right side (treated by microdebrider) and left side(treated by SMD) as regard postoperative patient satisfaction V 76 85 86 87 88 90 92 94 98
14. 15. 16. 17. 18. 19. Comparison between preoperative data versus postoperative data (7days) among side treated by microdebrider Comparison between preoperative data versus postoperative data (7days) among side treated by SMD Comparison between preoperative data versus postoperative data (1month) among side treated by microdebrider Comparison between preoperative data versus postoperative data (1month) among side treated by SMD Comparison between preoperative data versus postoperative data (3month) among side treated by microdebrider Comparison between preoperative data versus postoperative data (3month) among side treated by SMD 99 100 101 102 103 104 VI
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Introduction Introduction Chronic nasal obstruction is one of the most common human problems and a very frequent symptom in the ear, nose, and throat field. Hypertrophy of the inferior turbinates is the most frequent cause and may be related to allergy, pseudo allergy, nonallergic rhinitis with eosinophilic syndrome, and iatrogenic rhinopathy (Ottaviani et al., 2003). Even though medical treatments are frequently effective to restore comfortable nasal breathing, nasal obstruction is sometimes slightly improved, leading some patients to increase their consumption of local decongestants with a high risk of iatrogenic effects. In these cases, surgical reduction of inferior turbinates can be proposed. Inferior turbinate surgery is advocated for relief of symptoms in patients with chronic nasal congestion. Numerous reports substantiate the usefulness of inferior turbinate surgery (Salam & Wengraf, 1993). Various techniques are currently performed to reduce the volume of the mucosal (and sometimes bony) tissues of the inferior turbinates. Although most of these techniques provide satisfactory results for a more or less long period, adverse events are frequently observed after such treatments: postoperative bleeding, crusting, foul odor, pain, hyposmia, and synechia. No technique is perfect, and each is associated with known short- and long-term complications. The variety of surgical techniques available indicates the lack of consensus on the optimal technique (Sapci, 2003). -1-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Introduction Mucociliary function is an important defense mechanism that protects the respiratory system against bacteria and other foreign particles. Nasal mucociliary function is impaired in the majority of surgical reductions of the inferior turbinate. A wider nasal cavity does not necessarily mean that the nose functions are better. The goal of the surgical treatment should be to diminish complaints while preserving functions and optimal volume reduction together (Hol and Huizing, 2000). A large variety of surgical procedures have been described, each with its own advantages and imperfections. Any technique destroying the turbinate mucosa (surface electrocautery, cryosurgery, total turbinectomy) is more likely to lead to a loss of turbinate function, crusting, and adhesions. Some techniques of submucosal tissue reduction (Submucous cauterization SMC, injection of steroids or sclerosing agents) can preserve turbinate function but are generally found to offer only a limited or short-term result. A tailored resection of submucosal soft tissues _ turbinate bone (turbinoplasty) has been reported to provide the best long-term results in a large prospective comparative trial by Passali et al (Passali et al., 2003). During the last decade, a number of techniques for turbinoplasty have been described. Since it was first reported by Davis and Nishioka, most authors prefer powered instruments (Davis & Nishioka, 1996) and visualization by rigid endoscope. The extent of resection includes bone, submucosa, and lateral/inferior mucosa in most studies (Bielamowicz et al., 1999) however; some authors avoid mucosal damage and only resect bone or submucosa. Regardless of these variations, all authors agree that turbinoplasty is a superior technique for the management of inferior -2-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Introduction turbinate hypertrophy, producing a lasting and adequate decrease in turbinate size with low morbidity (Mori et al.,2002). Endoscopic microdebrider-assisted inferior turbinoplasty is a newly developed surgical technique. When compared with traditional surgical treatments, endoscopic microdebrider- assisted inferior turbinoplasty has the advantages of being minimally invasive, allowing the preservation of physiological nasal mucosa, and being a painless and tolerable procedure that is easily achieved with the patient under local anesthesia in an outpatient clinical setting (Van delden, 1999). On the other hand, submucosal cauterization (SMC) remains a very popular technique because of its technical ease and lack of complications (Fradis et al., 2002). Although recent studies preliminarily confirmed the effectiveness of turbinoplasty in relieving nasal obstruction, little is known about the prognostic factors determining the outcome. Theoretically, the allergic status of patients, by affecting the regional inflammatory condition of the nasal mucosa and submucosal tissue, might influence procedures aimed at reducing the volume of the inferior turbinate (Lee and Lee, 2006). -3-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Introduction Introduction Chronic nasal obstruction is one of the most common human problems and a very frequent symptom in the ear, nose, and throat field. Hypertrophy of the inferior turbinates is the most frequent cause and may be related to allergy, pseudo allergy, nonallergic rhinitis with eosinophilic syndrome, and iatrogenic rhinopathy (Ottaviani et al., 2003). Even though medical treatments are frequently effective to restore comfortable nasal breathing, nasal obstruction is sometimes slightly improved, leading some patients to increase their consumption of local decongestants with a high risk of iatrogenic effects. In these cases, surgical reduction of inferior turbinates can be proposed. Inferior turbinate surgery is advocated for relief of symptoms in patients with chronic nasal congestion. Numerous reports substantiate the usefulness of inferior turbinate surgery (Salam & Wengraf, 1993). Various techniques are currently performed to reduce the volume of the mucosal (and sometimes bony) tissues of the inferior turbinates. Although most of these techniques provide satisfactory results for a more or less long period, adverse events are frequently observed after such treatments: postoperative bleeding, crusting, foul odor, pain, hyposmia, and synechia. No technique is perfect, and each is associated with known short- and long-term complications. The variety of surgical techniques available indicates the lack of consensus on the optimal technique (Sapci, 2003). -1-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Introduction Mucociliary function is an important defense mechanism that protects the respiratory system against bacteria and other foreign particles. Nasal mucociliary function is impaired in the majority of surgical reductions of the inferior turbinate. A wider nasal cavity does not necessarily mean that the nose functions are better. The goal of the surgical treatment should be to diminish complaints while preserving functions and optimal volume reduction together (Hol and Huizing, 2000). A large variety of surgical procedures have been described, each with its own advantages and imperfections. Any technique destroying the turbinate mucosa (surface electrocautery, cryosurgery, total turbinectomy) is more likely to lead to a loss of turbinate function, crusting, and adhesions. Some techniques of submucosal tissue reduction (Submucous cauterization SMC, injection of steroids or sclerosing agents) can preserve turbinate function but are generally found to offer only a limited or short-term result. A tailored resection of submucosal soft tissues _ turbinate bone (turbinoplasty) has been reported to provide the best long-term results in a large prospective comparative trial by Passali et al (Passali et al., 2003). During the last decade, a number of techniques for turbinoplasty have been described. Since it was first reported by Davis and Nishioka, most authors prefer powered instruments (Davis & Nishioka, 1996) and visualization by rigid endoscope. The extent of resection includes bone, submucosa, and lateral/inferior mucosa in most studies (Bielamowicz et al., 1999) however; some authors avoid mucosal damage and only resect bone or submucosa. Regardless of these variations, all authors agree that turbinoplasty is a superior technique for the management of inferior -2-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Introduction turbinate hypertrophy, producing a lasting and adequate decrease in turbinate size with low morbidity (Mori et al.,2002). Endoscopic microdebrider-assisted inferior turbinoplasty is a newly developed surgical technique. When compared with traditional surgical treatments, endoscopic microdebrider- assisted inferior turbinoplasty has the advantages of being minimally invasive, allowing the preservation of physiological nasal mucosa, and being a painless and tolerable procedure that is easily achieved with the patient under local anesthesia in an outpatient clinical setting (Van delden, 1999). On the other hand, submucosal cauterization (SMC) remains a very popular technique because of its technical ease and lack of complications (Fradis et al., 2002). Although recent studies preliminarily confirmed the effectiveness of turbinoplasty in relieving nasal obstruction, little is known about the prognostic factors determining the outcome. Theoretically, the allergic status of patients, by affecting the regional inflammatory condition of the nasal mucosa and submucosal tissue, might influence procedures aimed at reducing the volume of the inferior turbinate (Lee and Lee, 2006). -3-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Aim of the work Aim of the work The aim of this work was to evaluate the results of endoscopic microdebrider-assisted inferior turbinopiasty and comparing them with submucosal cauterization of the inferior turbinates in the treatment of chronic inferior turbinate hypertrophy. -4-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Review Of literature Anatomy of the inferior turbinate The inferior turbinate plays a key role in the nasal airway. The structure consists of a bony core (conchal bone) with a soft tissue cover that consists of a fibroelastic stroma, submucosal glands, and cavernous sinusoids. The soft tissue portion of the inferior turbinate can be further broken down into medial and lateral portions that are separated by the internal conchal bone. Blood flow through the cavernous sinusoids is regulated by the autonomic nervous system and leads to subsequent enlargement or reduction in size of the inferior turbinate (Berger et al.,2006). Figure1. Endoscopic view of a normal inferior turbinate (right nasal side) -5-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Review Of literature Figure 2. Diagram showing the inferior turbinate with its bony part with covering periostium and arterial blood supply (Liu et al, 2009). Inferior nasal turbinates, project from the lateral wall of each side of the nose into the cavity. It receives its blood supply from branches of the sphenopalatine artery, the end artery of the internal maxillary branch of the external carotid artery. The lymphatic system of the nasal mucosa drains into the superficial cervical lymph nodes, which drain into the posterior cervical lymph nodes (Lee &Chen, 2004). The soft tissue is subsequently lined externally by pseudostratified, ciliated, columnar epithelium. This unique structure of the inferior turbinate allows it to play an important role in the filtration, humidification, and warming of inspired air, so as to protect the fragile alveolar epithelium of the lung from subsequent damage (Churchill et al.,2004). The nasal turbinates have extensive submucosal capillary bed and abundant serous and mucous glands so, the mucosal surface greatly contributes to the humidification, warming, and cleansing of the inspired air. This is made possible by the thick mass of cavernous -6-
Microdebrider-assisted Versus submucosal cauterization turbinoplasty Review Of literature tissue in between the submucosa and the bony skeleton. The conchal parenchyma is made up of arterioles, venules, and an extensive capillary bed embedded in loose connective tissue. Congestion and decongestion of the cavernous plexus is regulated by a complex autonomic nerve system that is influenced by a number of endogenous and exogenous factors (Bruintjes et al.,1998). Figure3: Inferior turbinate (Coronal section through its anterior part, MC (modified cold) staining. 1. Ciliated mucosa 2. Extensively vascularized parenchyma. 3. Turbinate bone, partially spongiotic. 4. lacrimal duct. (Huizing & de Groot, 2003) -7-