The aim of this study was to evaluate the safety and effectiveness of coblation-channeling in the treatment of inferior
turbinate hypertrophy. The study was conducted in the Department of ENT, Head and Neck Surgery, Split University
Hospital Center, Split, Croatia. Fifty-two patients with inferior turbinate hypertrophy who were refractory to medical therapy
were evaluated for coblation. The procedures were performed under local anesthesia using an ArthroCare ReFlexUltra
45 wand; three submucosal channels were made per turbinate. Clinical examinations, a questionnaire on individual nasal
symptoms (hyposmia, nasal drainage and post-nasal drip), a 10-cm visual analog scale (VAS) grading general nasal
obstructions, and rhinomanometry before and 8 weeks after the treatment were administered to assess treatment outcomes.
No adverse effects were encountered. Nasal breathing was significantly improved in all patients, decreasing the
VAS from a median of 7 (range 2–9) to 1 (range 0–3) (p<0.001). Total nasal resistance decreased from 0.44 Pa±0.50 to
0.24 Pa±0.11 (p=0.005). Improvement was statistically significant for all three symptoms (hyposmia [p=0.005], nasal
drainage [p=0.003] and post-nasal drip [p<0.001]). In this paper, we demonstrate that coblation-channeling of the hypertrophic
inferior turbinate is an effective and safe way to reduce nasal obstruction symptoms

Goran Kardum

Goran Račić

Željka Roje

English

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Coll. Antropol. 35 (2011) 1: 143–146Original scientific paperEfficacy and Safety of Inferior TurbinateCoblation-Channeling in the Treatment of NasalObstructions@eljka Roje1, Goran Ra~i}1 and Goran Kardum21 University of Split, Split University Hospital Center, Department of ENT, Head and Neck Surgery, Split, Croatia2 University of Split, School of Medicine, Department of Neuroscience and Scientific Methodology, Split, CroatiaA B S T R A C TThe aim of this study was to evaluate the safety and effectiveness of coblation-channeling in the treatment of inferiorturbinate hypertrophy. The study was conducted in the Department of ENT, Head and Neck Surgery, Split UniversityHospital Center, Split, Croatia. Fifty-two patients with inferior turbinate hypertrophy who were refractory to medical therapywere evaluated for coblation. The procedures were performed under local anesthesia using an ArthroCare ReFlexUltra45 wand; three submucosal channels were made per turbinate. Clinical examinations, a questionnaire on individual na-sal symptoms (hyposmia, nasal drainage and post-nasal drip), a 10-cm visual analog scale (VAS) grading general nasalobstructions, and rhinomanometry before and 8 weeks after the treatment were administered to assess treatment out-comes. No adverse effects were encountered. Nasal breathing was significantly improved in all patients, decreasing theVAS from a median of 7 (range 2–9) to 1 (range 0–3) (p<0.001). Total nasal resistance decreased from 0.44 Pa±0.50 to0.24 Pa±0.11 (p=0.005). Improvement was statistically significant for all three symptoms (hyposmia [p=0.005], nasaldrainage [p=0.003] and post-nasal drip [p<0.001]). In this paper, we demonstrate that coblation-channeling of the hy-pertrophic inferior turbinate is an effective and safe way to reduce nasal obstruction symptoms.Key words: nasal obstruction, turbinates, surgery, rhinomanometry, treatment outcomeIntroductionNasal obstruction is one of the oldest and most com-mon human complaints, and hypertrophy of the inferiorturbinate is a common cause of chronic nasal obstruc-tion1.Nasal obstruction is a considerable handicap for pa-tients and drastically affects their quality of life. Inferiorturbinate hypertrophy is usually observed with septal de-viations (compensatory hypertrophy) and is associatedwith chronic rhinitis2.Epidemiologic investigations in various European coun-tries have shown that up to 20% of the population has achronic nasal obstruction caused by turbinate hypertro-phy2,3. However, there is no agreement on how to treatthis problem. Pharmacological therapy (using intranasaltopical steroids, antihistamines or decongestants) is gen-erally the treatment of choice4. Nasal breathing is oftenonly slightly improved by conservative treatments, com-pelling patients to use local decongestants with a highrisk of undesirable side effects2. In these cases, surgicalreduction of the turbinate is an available option2–4.At least 13 different techniques have been introducedsince the last quarter of the 19th century (e.g., total orpartial turbinectomy, laser-assisted turbinoplasty, cryo-surgery, electrocautery using monopolar and bipolar tech-niques, radio-frequency volumetric tissue reduction andmicrodebrider submucosal reduction)1,2,4–6. The varietyof available surgical techniques indicates a lack of con-sensus on the optimal technique2.The majority of these techniques provide satisfactoryresults in terms of diminishing nasal obstruction, but ad-verse events are frequently observed. Bleeding, crusting,foul odor, pain, hyposmia, synechia, bone necrosis and in-fection are mainly caused by mucosal lesions that impairnasal mucociliary function1,2,5,7.143Received for publication July 09, 2010The ideal procedure for turbinate reduction shouldimprove nasal breathing with minimal discomfort or ad-verse reactions and should preserve the physiologicalfunction of the turbinates1,2,8. Several studies have report-ed that the use of radio-frequency energy for submucosaltissue ablation of the inferior turbinate can meet thesegoals1–3,6–15. The tissue response, as well as the extent ofvolume reduction caused by radio frequencies, was stud-ied by Powel et al. in the porcine tongue16. The safety andefficacy of radio frequencies in the human airway havebeen confirmed in soft palate and tonsillar tissue17,18.The procedure can be repeated without adverse effectsto maintain the best possible results19,20.We performed a prospective study on the efficacy andsafety of coblation for turbinate reduction. We used notonly subjective symptoms but an objective test as well toassess the efficacy of coblation in treating nasal obstruc-tions attributable to turbinate hypertrophy.Subjects and MethodsBetween June 2004 and June 2008, 52 patients withnasal obstructions due to inferior turbinate hypertrophywere enrolled in this prospective study. Exclusion criteriaincluded septal deformation, nasal polyposis and recentnasal surgery. All patients had been previously treated withconventional medical management without improvement.Before treatment, each patient underwent a medicalhistory and clinical examination. Patients graded theirnasal obstruction on a 10-cm visual analog scale (VAS). Ascore of 0 represented no obstruction, and a score of 10indicated complete obstruction. The patients also com-pleted a questionnaire measuring the severity of addi-tional symptoms: hyposmia, nasal drainage and post-nasaldrip, with scores ranging from 0 to 2 (0 – no symptoms, 1– mild to moderate, 2 – severe). These scores served asthe baseline measurements of nasal symptomatology.Each patient underwent active anterior rhinomano-metry (Rhinomanometer 300, ATMOS, Germany), whichassesses trans-nasal resistance depending on the trans-nasal pressure difference, DP (Pa), between the nostrilsand the choanae. The reference value of each measure-ment was defined as the resistance at a trans-nasal pres-sure of 150 kPa.Operations were performed in an out-patient facilitywith patients under local anesthesia from an injection of2 ccm of 2% lidocaine into each inferior turbinate. All sur-gical procedures were performed by the same surgeon(Z.R.) using an ArthroCare ReFlex Ultra 45 Wand (Arthro-Care Corp., Sunnyvale, CA, USA) to make three submuco-sal channels per turbinate (power: 6 W for each channel).Patients were discharged after two hours with instruc-tions to perform a post-operative treatment of a saline la-vage twice daily to prevent crusting and dryness andwere advised to continue with their usual daily activities.Follow-up visits were conducted at two and eightweeks after the operation to assess early adverse events.At the week-eight visit, patients completed the VAS andthe nasal questionnaire again to help us determine theirsubjective response to the therapy. Rhinomanometry wasalso performed after eight weeks to determine the objec-tive results of the coblation therapy.This study was approved by the Split University Hos-pital Medical Ethics Committee.Statistical analysisThe Statistica 7.1 software package (Stat Soft, Inc.,Tulsa, USA) was used to statistically analyze the data.Differences between the total nasal resistance before andafter the operation were statistically evaluated with t-testsfor dependent samples. The Wilcoxon Signed-Rank testwas used to evaluate the differences between nasal symp-tom scores before and after the operation. The Friedmantest was used to analyze the VAS data. A P-value of lessthan 0.05 was considered statistically significant.ResultsBetween June 2004 and June 2008, 52 patients (27men and 25 women) with a mean age of 28.5 years(range: 11 to 71 years) were enrolled in this trial.Patients tolerated the procedure well. None of themfelt discomfort during coblation due to overheating of thetissue. No significant epistaxis occurred during or afterthe procedure. Mild crusting was noted in three (5.7%)patients at the week-two follow-up visit; in these cases,crusting was observed in the head of the inferior tur-binate, corresponding to the areas that were puncturedto introduce the wand. None of the patients experiencedadverse events, including bleeding, crusting, dryness, in-fection, adhesion, or a worsening of obstruction, at theweek-eight follow-up visit.Nasal breathing was significantly improved in all pa-tients: the median VAS decreased from 7 (range 2–9) to 1(range 0–3) (p<0.001, Figure 1). Total nasal resistancedecreased from 0.44 Pa±0.50 to 0.24 Pa±0.11 (p=0.005,Figure 2).Patients reported improvement in each of the threescored symptoms after the procedure. The improvement@. Roje et al.: Coblation for Inferior Turbinate Reduction, Coll. Antropol. 35 (2011) 1: 143–146144012345678910pre-op post-op 8 weeksVAS*Fig.1. Mean nasal obstruction (VAS) pre- and post-op (8 weeks).*Significant difference compared to pre-op (p<0.001).in the symptoms was statistically significant for hypos-mia (p=0.005), nasal drainage (p=0.003), and post-nasaldrip (p<0.001, Figure 3).DiscussionThe ideal procedure for inferior turbinate reductionshould be performed in an office setting under local anes-thesia and should require minimal post-operative care,be clinically effective and preserve the mucosal and glan-dular architecture of the turbinate. The procedure shouldalso be repeatable in case inferior turbinate hypertrophywere to recur9,19.Despite the existence of various techniques for thetreatment of inferior turbinate enlargement, there is noconsensus in the literature as to which technique isbest1,2,4,5. However, there is a general consensus thatsubmucosal techniques have advantages in terms of pre-serving the overall nasal physiology4,5,10.Coblation seems to meet all of the criteria for an idealtreatment of inferior turbinate hypertrophy1,6,10–12,15.In our study, treatment efficacy was confirmed by thepatients’ subjective assessment of their nasal symptoms(obstruction, hyposmia, nasal drainage and post-nasaldrip) as well as by objective rhinomanometry. The me-dian VAS decreased from 7 (range 2–9) to 1 (range 0–3)(p<0.001), which confirms previous reports about the ef-ficacy of radio frequencies in the literature6,15.Utley et al.8, Seeger et al.3 and Rhee et al.13 also re-ported excellent results using radio-frequency submuco-sal tissue reduction to treat inferior turbinate hypertro-phy as assessed by subjective scores from patients. In aplacebo-controlled study using radio frequencies, Neaseet al. reported very similar results9.According to Atef et al., the radio-frequency proce-dure can be repeated without any additional adverse ef-fects, thus allowing better long-term results to be main-tained20. Porter et al. confirmed that good results weremaintained for two years with this procedure11.In our study, a comparison of rhinomanometry per-formed before the surgery and eight weeks after the sur-gery showed a statistically significant difference in nasalresistance, from 0.44 Pa±0.50 to 0.24 Pa±0.11 (p=0.005),which is consistent with the acoustic rhinomanometryresults obtained by Fischer et al.14 and Rhee et al.13 afterradio-frequency procedures.In our study, there were no adverse effects that de-manded additional surgical treatment. Crusting was not-ed in three (5.7%) patients at the week-two follow-upvisit and was located in the head of the inferior turbinate,corresponding to the puncture area where the wand wasintroduced. None of the patients reported adverse eventsat the week-eight follow-up visit, which confirms previ-ous safety reports found in the literature3,7,13,14.Although the vast majority of proposed methods forthe treatment of inferior turbinate enlargement meetthe goal of providing better nasal patency1,2,4,5,19,21, themain advantage of this technique is its preservation ofthe architecture and function of the mucosa1,2.ConclusionsCoblation channeling of the inferior turbinate is a safe,highly efficacious procedure for out-patient clinic-basedinferior turbinate reduction. There are no side effects ineither the early or late post-operative periods, and thereis minimal patient discomfort during the procedure.Thus, coblation tissue reduction of the inferior turbi-nate meets all of the criteria for an ideal method for thetreatment of inferior turbinate hypertrophy.AcknowledgementsThe authors thank ArthroCare for technical support(free use of the bipolar devices during the study).There were no finacial interest for authors or forArthroCare in this study.@. Roje et al.: Coblation for Inferior Turbinate Reduction, Coll. Antropol. 35 (2011) 1: 143–146145RMM (before) RMM (after)0,150,200,250,300,350,400,450,500,550,600,65**MeanMean±SEMean±1,96*SEFig. 2. Rhinomanometry (nasal resistance) pre- and post-op (8weeks). *Significant difference compared to pre-op (p=0.005).0 10 20 30 40 50 60 70 80 90 100NoneMildSevereNoneMildSevereNoneMildSeverePercent of patients (%)HyposmiaNasaldrainagePostnasaldripPre-operativePost-operativeFig. 3. Pre- and post-operative (8 weeks) symptoms.R E F E R E N C E S1. SAPCI T, SAHIN B, KARAVUS A, AKBULUT UG, Laryngoscope,113 (2003) 514. — 2. CAVALIERE M, MOTTOLA G, IEMMA M, Otolaryn-gol Head Neck Surg, 133 (2005) 972. — 3. SEEGER J, ZENEV E, GUN-DLACH P, STEIN T, MUELLER G, Laryngoscope, 113 (2003) 130. — 4.HOL MK, HUIZING EH, Rhinology, 38 (2000) 157. — 5. PASSALI D,LAURIELLO M, ANSELMI M, BELLUSSI L, Ann Otol Rhinol Laryngol,108 (1999) 569. — 6. KIZILKAYA Z, CEYLAN K, EMIR H, YAVANOGLUI, UNLU I, SAMIM E, AKAGUN M, Otolaryngol Head Neck Surg, 138(2008) 176. — 7. LI KK, POWELL NB, RILEY RW, TROELL RJ, GUILLE-MINAULT C, Otolaryngol Head Neck Surg, 119 (1998) 569. — 8. UTLEYDS, GOODE RL, HAKIM I, Laryngoscope, 109 (1999) 683. — 9. NEASECJ, KREMPL GA, Otolaryngol Head Neck Surg, 130 (2004) 291. — 10.BHATTACHARYYA N, KEPNES LJ, Otolaryngol Head Neck Surg, 129(2003) 365. — 11. PORTER MW, HALES NW, NEASE CJ, KREMPL GA,Laryngoscope, 116 (2006) 554. — 12. FRIEDMAN M, TANYERI H, LIMJ, LANDSBERG R, CALDARELLI D, Laryngoscope, 109 (1999) 1834. —13. RHEE CS, KIM DY, WON TB, LEE HJ, PARK SW, KWON TY, LEECH, MIN YG, Laryngoscope, 111 (2001) 153. — 14. FISCHER Y, GOSE-PATH J, AMEDEE RG, MANN WJ, Am J Rhinol, 14 (2000) 355. — 15.FARMER SE, QUINE SM, ECCLES R, J Laryngol Otol, 123 (2009) 309.— 16. POWELL NB, RILEY RW, TROELL RJ, BLUMEN MB, GUILLE-MINAULT C, Chest, 111 (1997) 1348. — 17. POWELL NB, RILEY RW,TROELL RJ, BLUMEN MB, GUILLEMINAULT C, Chest, 113 (1998) 1163.— 18. ROJE @, RA^I] G, PE[UTI] PISAC V, \OGA[ Z, TIMMS M, CollAntropol, 33 (2009) 293. — 19. FARMER SE, ECCLES R, J Laryngol Otol,28 (2006) 1. — 20. ATEF A, MOSLEH M, EL BOSRATY H, ABD EL FA-TAH B, FAHTI A, Am J Rhinol, 20 (2006) 25. — 21. FARMER SE, EC-CLES R, Rhinology, 44 (2006) 234.@. RojeUniversity of Split, Split University Hospital Center, Department of ENT, Head and Neck Surgery, Spin~i}eva 1,21000 Split, Croatiae-mail: zroje@kbsplit.hrU^INKOVITOST I SIGURNOST KOBLACIJSKOG TUNELIRANJA DONJIH NOSNIH [KOLJKIU LIJE^ENJU NOSNE OPSTRUKCIJES A @ E T A KCilj ovog istra`ivanja bio je procijeniti u~inkovitost i sigurnost koblacijskog tuneliranja hipertrofi~nih donjih nosnih{koljki u lije~enju nosne opstrukcije. Studija je provedena u Klinici za bolesti uha, nosa i grla s kirurgijom glave i vrataKBC Split, Split, Hrvatska. Uklju~ena su 52 pacijenta s hipertrofijom donjih nosnih {koljki refrakternih na konzerva-tivno lije~enje. Operacije su ra|ene u lokalnoj anesteziji koriste}i ArthoCare ReFlexUltra 45 wand; tri submukozna ka-nala po svakoj nosnoj {koljki. U procjeni rezultata lije~enja koristili smo: klini~ki pregled, upitnik o individualnim nosnimsimptomima (hiposmija, curenje iz nosa, postnazalni drip), 10-cm vizualno-analognu skalu (VAS) za procjenu nosneopstrukcije i rinomanometriju prije operacije i 8 tjedana nakon operacije. Tijekom ispitivanja nije zabilje`ena nijednanuspojava. Disanje kroz nos se zna~ajno pobolj{alo u svih pacijenata, smanjuju}i VAS od mediana 7 (raspon 2–9) na 1(raspon 0–3) (p<0,001). Ukupni nosni otpor smanjio se od 0,44 Pa±0,50 na 0,24 Pa±0.11 (p=0,005). Pobolj{anje je bilostatisti~ki zna~ajno za sva tri individualna simptoma (hiposmija [p=0,005], curenje iz nosa [p=0,003] i postnazalni drip[p<0,001]). U ovom istra`ivanju pokazali smo da je koblacijsko tuneliranje hipertrofi~nih donjih nosnih {koljki u~inko-vit i siguran na~in u smanjivanju simptoma nosne opstrukcije.@. Roje et al.: Coblation for Inferior Turbinate Reduction, Coll. Antropol. 35 (2011) 1: 143–146146

Efficacy and Safety of Inferior Turbinate Coblation-Channeling in the Treatment of Nasal Obstructions

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