COBLATION REDUCTION OF HYPERTROPHIED INFERIOR TURBINATE WITH AND WITHOUT COBLATION OF SEPTAL BODY SWELLING

Taha Mohamed, MD(1),Hamada Fadl,MD(2),Ahmed Shehata,MD(3), Yasser Mandour,MD(4).

Abstract

Objectives: This study aimed to evaluate the effect of septal body swelling on nasal airway in patients having both hypertrophied inferior turbinate and septal body.

Study design: Prospective randomized study.

Patients and methods: 60 patients complaining of persistent nasal obstruction due to both turbinate hypertrophy and septal body hypertrophy were included in this study. All patients were evaluated subjectively (NOSE score) and objectively by endoscopic examination and acoustic rhinometry. This was done for each patient preoperatively and 3 months postoperatively. Patients were divided randomly into 2 groups A &B each included 30 patients. Group A patients underwent submucosal coblation turbinate reduction while patients of group B underwent combined submucosal coblation reduction of both inferior turbinate and septal body.

Results: There was a significant difference in group A in relation to group B as regard nasal congestion (P = 0.027), nasal obstruction (P= 0.38), and sleeping problems (P= 0.033) while no significant difference in other NOSE questionnaire parameters. From acoustic rhinometry findings of both groups, 3 months postoperatively, We found that there was a significant difference in group B in relative to that in group A. Nasal resistance in RT side (P= 0.043) and in LT side (P= 0.033), also nasal volume in RT side (P= 0.031) and in LT side (P= 0.42).

Conclusion: From the obtained results we believed that combined volume reduction of both hypertrophied septal body and inferior turbinate using submucosal coblation is simple, safe and more effective than the coblation of inferior turbinate alone.

Key words: Nasal septal body, inferior turbinate, acoustic rhinometry, submucosal coblation and volume reduction.

Introduction

The nasal airway serves as the primary conduit for inspired air to reach the lower respiratory tract. Different anatomic factors may contribute to the subjective sensation of decreased nasal airflow. It is difficult to assess the relative importance of individual factors contributing to nasal obstruction and to decide on the therapy most likely to be effective in restoring satisfactory nasal breathing [1]. The internal nasal valve constitutes the bottle neck of the nose. It is responsible for almost half of the total airway resistance [2].

Nasal breathing impairment occurs if the nasal valve area is constricted by any pathology such as hypertrophy of the inferior turbinate, septal deviations, bony constrictions of the pyriform aperture, anatomic variations of the cartilaginous lateral nasal wall or scarred stenosis of the nasal valve [3].

A significant rise in pressure is recorded in particular within the first two centimeters of the air passage through the nose [4]. Inferior turbinate hypertrophy is a common cause of chronic nasal obstruction. This hypertrophy mostly results from chronic allergic or non allergic rhinitis which treated conservatively with topical corticosteroids, antihistamines, decongestants, and immunotherapy [5]. However, medical therapy is frequently ineffective. So, surgical intervention is commonly indicated for its treatment. Different surgical modalities are performed aiming volume reduction of inferior turbinate including partial turbinectomy, laser-assisted turbinoplasty, submucosal resection, electrocautery, turbinate outfracture, radiofrequency , and most recently coblation is a widely used surgical technique [6].

The nasal septal body is a widened area of the nasal septum located superior to the inferior turbinate and anterior to the middle turbinate. [7]. It has a thicker mucosal covering than in the other portions of the nasal septum and has an intimate relationship with the internal nasal valve. The high proportion of venous sinusoids within the swell body suggests the capacity to alter nasal airflow [8]. It contains vasoactive tissue that may behave in a manner similar to the inferior turbinate. Situated in the nasal valve region, the nasal septal body may undergo changes that alter nasal anatomy and airflow patterns [9]. It plays an important role in the regulation of nasal airflow. Because it contains venous sinusoids, it is also called the septal turbinate [10].

Various objective methods to investigate nasal patency have been described; two of these are most commonly used: rhinomanometry and acoustic rhinometry. Acoustic rhinometry provides a

reflection of the anatomy of the nasal passages, from which the volume and the geometry of the nasal cavity can be deduced [11].

Objectives

This study aimed to evaluate the effect of septal body swelling on nasal airway in patients having both hypertrophied inferior turbinate and septal body . This was carried out by coblation reduction of hypertrophied inferior turbinate with and without coblation of septal body swelling.

Patients and methods

A prospective randomized controlled study was carried out on 60 patients complaining of persistent nasal obstruction during the period from January 2014 till July 2015. All patients were selected from ORL department, Benha University Hospitals. The study was approved by the medical ethic committee. All patients included in this study signed a written consent. Ages of patients had been included in this study ranged from 18 years up to 56 years.

All selected patients enrolled in this study were having inferior turbinate hypertrophy and septal body hypertrophy refractory to medical therapy (topical corticosteroids, antihistamines) for at least three months.

Excluded from this study patients with any other sinonasal pathological conditions (nasal polyp, significant septal deviation, concha bullosa, neoplasm of nasal cavity), patients with previous history of sinonasal surgery. Also patients with bleeding or coagulation disorders were excluded.

All selected patients were exposed to the following:

Subjective assessment;

Complete history, standardized questionnaire used in this study according to Leonardo, et al [12]. Nasal Obstruction Symptom Evaluation (NOSE) scale was carried out preoperatively, and at the end of the study (3 months postoperatively).

This is a scale with five questions about nasal symptoms to which patients assign scores varying between 0 and 4, according to symptom intensity [Table 1]. At the end, the total score given by the patient is multiplied by 5 resulted in scores which vary between 0 (patients without symptoms) and 100 (patients with the most intense possible symptoms).

Table 1. NOSE Questionnaire:

complaint No Mild Moderate Bad Sever

1- Nasal congestion 0 1 2 3 4

2- Nasal obstruction 0 1 2 3 43- Problems in breathing through the nose 0 1 2 3 4

4- Sleeping problems 0 1 2 3 45- Difficulties in breathing through the nose during exercise or physical effort

0 1 2 3 4

Objective assessment;

General examination and full otorhinolaryngeal examination with detailed rhinologic examination (anterior rhinoscopic and endoscopic examinations) were performed [Figure 1].

All patients assessed by acoustic rhinometry in Hearing and Speech Institute in Cairo (model AR-1003, Hood Laboratories, Pembroke, Mass). All examinations were done 10 to 15 minutes after applications of 0.05% oxymetazolin spray, and suctioning of the nasal cavity to clear any secretions, this was performed to eliminate the effect of the nasal cycle, and this was done in acoustic rhinometry room with the same temperature and humidity for all patients to minimize artifacts from environmental changes [13].

All patients had been submitted to acoustic rhinometry preoperatively and 3 months postoperatively.

Figure (1) shows endoscopic view of right and left nasal cavities of patient with hypertrophied inferior turbinate and septal body .

C.T Nose and paranasal sinus coronal view was performed for each patient preoperatively to confirm our diagnosis and to exclude any hidden pathology [Figure 2].

Figure (2) shows coronal CT of 2 patients with hypertrophied inferior turbinate and septal body.

Surgical procedures;

The patients were divided randomly into 2 groups A &B each included 30 patients. Group A patients underwent submucosal coblation turbinate reduction while patients of group B underwent combined submucosal coblation reduction of both inferior turbinate and septal body.

All surgical procedures were performed by the same Surgeon under general anesthesia using the device “Coblator II ENT” (Arthrocare Corp, Sunnyvale, CA).

According to Siméon et al [14], the electrode was dipped in physiological saline to form a highly ionized active plasma field on the tissue. As regard coblation of hypertrophied inferior turbinate ; three submucosal parenchymatous ablations were performed, with coblation entry at level 6 and coagulation exit. The wand remained in each place for 15 seconds. The turbinate therefore received a total of 45 seconds of coblation.

As regard the septal body swelling we performed coblation according to Catalano et al [15], the wand level of 4 was submucosaly inserted parallel to the septum, similar to the technique of the needle used for injection of the local anesthesia. The wand remained in place for about 2 to 5 seconds per pass, looking for early blanching and contraction of the overlying mucosa [Figure 3]. Another parallel pass was done in case of marked septal body hypertrophy depending upon its size, moving vertically along the area of swelling from inferior to superior. In case of any bleeding point, homeostasis' was done using the same electrode on coagulation setting. So in all our patients no need for nasal packs.

Figure (3) shows endoscopic pictures of right and left nasal cavities of a patient with ITH and SBH. (A, B) insertion of coblation in SBH. (C,D) immediately after coblation showing blanching. (E,F) 1 month post op. showing volume reduction of both IT and NSB and the MT middle turbinate appear.(G,H) 3

month post op.

Postoperative care:

All patients were discharged the same day postoperatively. Prophylactic antibiotic was prescribed and saline nasal wash was recommended for 15 days. Follow up of the patients were regular weekly in the first month and monthly for 3 months postoperatively. At the last visit follow up all patients were submitted to subjective evaluation using the same questionnaire (NOSE) done preoperatively and objective evaluation which included (anterior rhinoscopy, endoscopic examination and acoustic rhinometry). It was performed by another rhinologist who was blinded to the operative procedures.

The collected data were recorded and analyzed using the computer program SPSS (Statistical Package for Social Science) y version 16.

Results

Patients of our study consisted of 60, they were divided into 2 groups A and B each included 30 patients. Group A patients underwent submucosal coblation of inferior turbinate , while group B patients underwent combined submucosal coblation of both inferior turbinate and septal body.

Group A patients included 18 men and 12 women their ages ranged from 18 up to 56 years old with mean ± SD (28.73±13.39) while group B patients were 16 men and 14 women their ages ranged from 19 up to 50 years with mean ± SD (26.66±6.91). There was no significant difference between both groups regarding age and sex distributions.

As regard the subjective assessment of the patients in group (A) we found postoperative significant improvement in nasal congestion which was bad to sever in 29 patients (96.7%) preoperatively and became mild in 27 patients (90%) postoperatively. There were 28 patients (93.3%) with bad to sever nasal obstruction which became with no or mild obstruction in 29 patients (96.6%). Sleeping problems were bad to sever in 19 patients (63.3%) but postoperatively 13 patients (43.3%) had no sleeping problems. Also there was significant improvement in breathing during exercise [Table 2].

Table 2 NOSE score in group A

Complaint Nasal congestion

Nasal obstruction

Difficulties in breathing

through nose

Sleeping problems

Difficult breathing

during exercise

Pre Post Pre Post Pre Post Pre Post Pre Post

No 0 12 0 13 0 17 1 14 0 13

Mild 0 15 0 16 0 13 1 15 0 14

Moderate 1 3 2 1 6 0 9 1 1 3

Bad 15 0 16 0 15 0 15 0 14 0

Sever 14 0 12 0 9 0 4 0 15 0

Fisher exact test ^

^57.0 ^57.33 ^60.0 ^48.92 ^57.0

P value 0.001 0.001 0.001 0.001 0.001

Group (B): We observed postoperative high significant improvement in all NOSE score. Nasal congestion was from bad to sever in 28 patients (93.3%) and became from no to mild congestion in 30 patients (100%). There were 27 patients (90%) with bad to sever nasal obstruction who became with no or mild obstruction in 30 patients (100%). Sleeping problems were bad to sever in 24 patients (80%) but postoperatively 23 patients (76.6%) had no sleeping problems. Also the other NOSE parameters showed high significant improvement. [Table 3].

Table 3 NOSE score in group B

Complaint Nasal congestion

Nasal obstruction

Difficulties in breathing

through nose

Sleeping problems

Difficult breathing

during exercise

Pre Post Pre Post Pre Post Pre Post Pre PostNo 0 21 0 21 0 20 0 23 0 14Mild 0 9 0 9 0 10 0 7 0 14Moderate 2 0 3 0 4 0 6 0 2 2Bad 15 0 15 0 12 0 16 0 16 0Sever 13 0 12 0 14 0 8 0 12 0Fisher exact test ^

^60.0 ^60.0 ^60.0 ^60.0 ^56.0

P value 0.001 0.001 0.001 0.001 0.001

Postoperative comparison between the two groups we found that there was a significant difference in group B in relation to group A as regard nasal congestion (P = 0.027), nasal obstruction (P= 0.38), and sleeping problems (P= 0.033) while no significant difference in other NOSE questionnaire parameters.

Analysis of data obtained from acoustic rhinometry which done preoperatively and 3 months postoperatively we found in group (A): The mean of nasal resistance was (10.75±4.75) in RT side and (10.24±4.56) in LT side which became (6.62±3.29) and (6.27±3.33) respectively with significant improvement.

The mean of nasal volume in RT side was (8.43±1.72) and in LT side was (8.37±1.63) which became (10.63±1.89) and (10.75±1.79) respectively with significant increase [Table 4].

Table( 4 ) nasal resistance and volume in group ASide RT LTTime Pre. Post. Pre. Post.

Nasal Resistance 10.75±4.75 6.62±3.29 10.24±4.56 6.27±3.33P- value 0.041* 0.033*Nasal volume 8.43±1.72 10.63±1.89 8.43±1.72 10.75±1.79P- value 0.036* 0.024**

In group (B): The mean of nasal resistance was (10.31±4.33) in RT side and (9.94±3.92) in LT side which became (4.98±2.81) and (4.85±2.70) respectively with high significant improvement .

The mean of nasal volume was (8.06±2.21) in RT side and (8.05±1.95) in LT side, which became postoperatively (11.82±2.24) and (11.60±1.80) respectively with high significant increase [Table 5].

Table (5 ) nasal resistance and volume in group BSide RT LTTime Pre. Post. Pre. Post.

Nasal Resistance 10.31±4.33 4.98±2.81 9.94±3.92 4.85±2.70P- value 0.001** 0.001**Nasal volume 8.06±2.21 11.82±2.24 8.05±1.95 11.60±1.80P- value 0.001** 0.001**

Comparison of acoustic rhinometry findings between both groups, 3 months postoperatively, We found that there was a significant difference in group B in relative to that in group A. Nasal resistance in RT side (P= 0.043) and in LT side (P= 0.033), also nasal volume in RT side (P= 0.031) and in LT side (P= 0.42).

As regards postoperative rhinoscopic and endoscopic assessment we examined the patients to check any postoperative complications. There was no any case with septal perforation , nasal synachia or smell disorder. We observed few crusts in 8 cases of group B and in 2 cases of group A one week postoperatively which were disappeared on next week.

Discussion

The nasal valve area is not a single structure, but a complex three dimensional construct consisting of several morphological structures. It is formed by the soft cartilaginous lateral nasal wall, the anterior septum with the swell body, the head of the inferior turbinate and the osseous pyriform aperture [16].

The role of inferior turbinate hypertrophy in the reduction of nasal airflow is well established. Some patients respond to medical therapy while others not respond. In these cases surgical approach is considered [17].

Different terms and definitions had been used for describing the septal body swelling. Yu et al[18], called it as septal body, septal turbinate or nasal swell body.

Many studies had been performed to analyze the septal body structure, function and its relations. Elwany et al [19], conducted a study to assess the histological structure of the septal body mucosa and the difference between it and adjacent septal mucosa. They performed their study on 30 cadaveric specimens (60 sides). They found that the histological features of the septal body mucosa are thicker epithelium and more glandular acini and blood sinusoids than the rest of septal mucosa.

Setlur and Goyal [20], studied the relationship between septal body size and septal deviation. They used CT scan to study the septum as well as nasal soft tissues, in addition measurement of the degree of septal deviation. They characterized the septal body as a dynamic structure. As they found Patients with symmetric septal body dimensions tended to have little or no septal deviation at the site of the septal body. Conversely, patients with asymmetric septal body hypertrophy tend to have septal deviation contralateral to the side of the hypertrophy. This relationship seemed to be similar to that seen between septal deviation and contralateral inferior turbinate hypertrophy. They believed that both of these structures can undergo remodeling in response to changes in airway anatomy and alterations in airflow.

Turhan et al [10], studied the relation of nasal septal body and inferior turbinate sizes in different subjects grouped by sex and age. They investigated the area of the septal body as well as the area of inferior turbinate on the right and left sides separately using coronal CT scan slices. The septal body

was determined to be fusiform in shape and tapered gently at its anterior aspect. They concluded that the septal body may play a role in nasal physiology similar to that of a turbinate.

In patients with inferior turbinate hypertrophy resistent to conservative management,the surgical approach is recommend . At first, surgery consisted in almost total resection of the inferior turbinates. Partial reduction procedures were then developed, to conserve the air-conditioning functions, which this organ mainly provides [21].

Surgical reduction procedures include partial resection, submucosal diathermy, turbinate outfracture and most recently, submucosal radiofrequency or coblation. The severity of complications, therefore, vary with increasing degrees of invasiveness and range from minor bleeding to significant hemorrhage, synachiae, crusting, foul odor, pain, hyposmia, and chronic dryness [22].

Passali et al [17], performed their study on patients with inferior turbinate hypertrophy refractory to medical therapy. They studied the effect of radiofrequency versus coblation under local infiltration anesthesia. They compared their results with the traditional classic turbinate surgeries. They concluded that submucosal coblation or radiofrequency with preservation of nasal mucosa minimize the interference with the respiratory, olfactory and defensive physiological activities of the nose.

Our study agree with a study was performed by Yu et al [18], in the type of selected patients and nearly the same subjective & objective evaluation were used, but disagree in the operative procedure. They conducted their study on two groups with septal body and inferior turbinate hypertrophy that were refractory to medical therapy. One group included 25 patients underwent conventional inferior turbinoplasty only. The second group included 26 patients whom underwent combined bilateral volume reduction of hypertrophied septal body and turbinoplasty. They used microdebrider in reduction of septal body swelling. Microdebrider tip was inserted through an incision into the submucosal pocket and the septal body soft tissue was removed in an oscillating fashion. Although they performed different procedures, their results were coinciding with ours.

They used the subjective VAS, including nasal obstruction, rhinorrhea, itching, and sneezing, which had significantly improved at 3 months after treatment in both groups (P<0.001). Improvement of nasal obstruction in the septal body group was greater than that in the inferior turbinate group at 3 months (P<0.05). Acoustic rhinometry demonstrated a significant increase in the cross-sectional area and nasal volume in both groups 3 months after surgery. The postoperative change in nasal volume was higher in the septal body group (P<0.05). They did not record any adverse reactions such as bleeding, infection, adhesions, or olfactory changes.

In our study we found a significant improvement in all parameters in group A and highly significant improvement in group B. when we compared results of both groups we found that there was significant difference in nasal congestion (P = 0.027), in nasal obstruction (P= 0.38), and in sleeping problems (P= 0.033) while no significant difference in other NOSE questionnaire parameters.

Regarding acoustic rhinometry data, we found that the improvement was greater in group B than group A with significant difference in nasal resistance (RT side P= 0.043 and LT side P= 0.033), also a significant difference in nasal volume (RT side P= 0.031 and LT side P= 0.42).

Our study agree with another study was performed by Catalano et al [15], who used the same coblation reduction for septal body swelling. But they disagree with us in type of selected patients (those with septal body hypertrophy whom were enrolled after persistent nasal obstruction following septoplasty, turbinate reduction and internal nasal valve repair). They performed their procedures under local infiltration anesthesia. Evaluation was determined by changes in the NOSE score the same we used in our study. They newly developed nasal septal body grading scale before, and six months after septal body coblation. This grading was based on endoscopic visualization of the middle turbinate (MT): 1= > 50% MT visualized; 2 = < 50% MT visualized; 3 = no MT visualized.

They conducted their study on 60 patients whom were followed for 3 and 6 months. The mean pre-operative NOSE score was 41.6 and mean NSB grade was 2.5. At 3 months, the mean post-operative NOSE score was 17 with NSB grade of 1. At 6 months, the NOSE score was 21 and the NSB grade was 1.2 (p<.05). Thus, statistically significant improvement in NOSE scores and standardized NSB grading was noted at 3 and 6 months post coblation of NSB tissue. There was one asymptomatic small septal perforation noted, and 5 patients needed retreatment at 6 months.

In our technique we preserved the overlying mucosa on both the turbinate and the septal body to decrease the complications as synachiae. We observed few crusts in 8 cases of group B and in 2 cases of group A one week postoperatively. These crusts resolved rapidly on next week by regular saline nasal irrigation.

Conclusion

Combined volume reduction of both hypertrophied inferior turbinate and septal body swelling using submucosal coblation is simple, safe and more effective than the coblation of inferior turbinate alone.

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