Ear, Nose and Throat (ENT), Head and Neck Surgery
Copyright Vincent Specialist Solutions Sdn Bhd 2016. All rights reserved
Last update: 10/1/13
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their
decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
“ MY NOSE IS ALWAYS BLOCKED !”
Keen to know more about
Nasal
Surgery
Services
provided here ?
What are nasal turbinates ?
These
are
normal
structures
projecting
from
the
sidewall
of
each
nostril.
There
are
three
turbinates
(inferior,
middle,
and
superior)
on
each
side
of
the
nose
(occasionally
four
in
some
individuals,
the
fourth
being
called
the
supreme
turbinate).
Turbinates
are
covered
by
the
normal
nasal
lining/mucosa
and
it
functions
to
clean,
moisten/humdify
and
warm
the
air
we
breathe
as
it
moves
through
our
noses
into
our
lungs.
On
the
surface
of
this
lining,
normal
mucociliary
function
(a
blanket
of
cells
with
tails
invisible
to
the
naked
eye
moving
in
a
synchronised
orderly
pattern
to
move
nasal
discharge
in
a
certain
direction)
takes
place
to
ensure
proper
clearance
of
nasal
mucus
onto
the
back
of
our
nose
and
subsequently
into
the
throat.
Mucociliary
function
is
an
important
defense
mechanism
that
protects
the
respiratory
system
against
bacterial
infection
and
other
foreign particles.
One of the major and commonest causes of chronic nasal airway obstruction is enlargement (hypertrophy) of the inferior turbinate.
Usually the lowest turbinate also known as the inferior turbinate enlarges in conditions like allergic rhinitis (AR), vasomotor rhinitis (non-allergic
rhinitis) and or just simply born with an enlarged structure (compensatory hypertrophy secondary to deviated nasal septum (DNS). The middle
turbinate can also be enlarged in chronic rhinosinusitis (CRS), allergic rhinitis or congenital
conditions (concha bullosa).
What can it look like ?
There are other conditions which may resemble enlarged turbinate. These can all be reliably
differentiated using a nasal endoscopic examination in the ENT clinic.
Can this condition be treated ?
Yes, sure. Please read on…
What are the aims of treatment ?
1.
Reduce volume
2.
Preserve function (mucosa-sparing)
The
main
goal
of
turbinate
surgery
should
be
the
reduction
of
the
volume
of
tissue
over
the
enlarged
turbinate therefore structurally enlarging the passageway through which air passes into the nose.
However,
a wider nasal cavity
does not
necessarily or automatically mean the nose functions better.
It
is
also
extremely
important
to
preserve
the
normal
function
of
the
nasal
lining
to
maintain
the
normal
mucociliary
function,
regulating
the
humidification
and
temperature
of
the
inspired
air.
Removal
of
too
much
normal
tissue
can
predispose
to
'
empty
nose
syndrome
(ENS)
'
where
the
nose
loses
its
normal
function
of
humidification.
Paradoxically,
patients
with
ENS
feel
as
though
their
nose
is
always
blocked,
and
that
they
cannot
take
in
sufficient
air
through
their
nose.
The
patient
may
also
complain
of
frequent
crusting
in
their
nose, sometimes with a foul smell.
Therefore
it
is
important
to
remove
just
enough
nasal
tissue
to
breathe
without
blockage
and
at
the
same
time main normal function of the nose.
At
the
same
time,
these
are
to
be
achieved
with
minimal
adverse
or
side
effects,
inconvenience
and/or
complications
to
the
patient.
This
include nasal bleeding, unwanted scarring.
How can this condition be treated ?
Many different surgical methods are currently available.
Treatment
of
nasal
inferior
turbinate
hypertrophy
varies
include
conservative/non-surgical
treatment,
including
using
corticosteroid
nasal
sprays,
oral
antihistamines
with
decongestants
and
topical
decongestant.
This
also
treats
the
underlying
allergic
condition
eg.
AR
predisposing
to
enlarged
turbinates.
This
generally
takes
a
longer
duration
to
work
and
symptoms
can
likely
recur.
On
the
other
hand,
newer
surgical
modalities
include
microdebrider-assisted
inferior
turbinoplasty
(MAIT)
,
radiofrequency
volume
reduction/ablation
or
laser
surgery
.
Turbinectomy
has
also
been
used
and
the
degree
of
resection
of
the
offending turbinate ranges from partial to total, depending on severity of disease/symptoms and surgeon's preference.
Microdebrider
refers
to
modern
cutting
blade
employed
to
efficiently
suck
and
cut
tissues
simultaneously.
It
is
used
in
many
ENT
surgeries
to
produce
a
clean
cut
edge.
Currently
new
techniques
of
Microdebrider-assisted
inferior
turbinoplasty
(MAIT)
involves
creating
a
pocket
under
the
surface
of
the
turbinates
to
removed
the
bulk
of
turbinates.
This
spares
the
mucosa
from
damage
as
compared
to
the
older
conventional
techniques
of
removing
the
mucosa.
It
also
significantly
differs
from
turbinectomy
where
usually
the
turbinate
bone
is
partially
or
totally
removed
together with the overlying mucosa- a more destructive or invasive procedure.
Radiofrequency
tissue
reduction
is
a
modern
surgical
procedure
that
uses
radiofrequency
heating
to
induce
submucosal
tissue
(nasal
tissue
underneath
the
lining,
therefore
sparing
the
mucosa)
destruction,
leading
to
the
reduction
of
tissue
volume.
It
causes
a
thermal
change
that
should
occur
in
the
deep
mucosa
without
damaging
the
surface.
The
healing
process
intentionally
induces
scarring
that
leads
to
tissue
volume
reduction,
thus achieving the surgical aim.
Lasers
in
medicine
comes
in
many
forms,
eg.
carbon
dioxide
(CO2),
Nd-YAG,
diode,
gold
lasers
and
newer
ones
are
on
the
horizon.
In
ENT
surgeries,
carbon dioxide laser
is most commonly used. Currently available CO2 laser involves changes over the lining of the nose.
Figure A: Moderately enlarged inferior
turbinates (IT); Figure B: an inflammed
and grossly enlarged IT; Figure C: Very
enlarged middle turbinate (MT), concha
bullosa with normal IT. (S=septum)
S
IT
A
B
C
MT
IT
S
© Vincent Tan ENT
B
S
IT
What evidence exist for the usage of the different techniques ? What are the pros and cons ?
Based on medical evidence from medical journals as referenced below:
RELATED LINKS
References from Medical Journals:
Based on medical evidence from medical journals as referenced below:
Figure A: Microdebrider in a nasal tumour surgery - notice the cutting edge of the blade (red arrow). In MAIT, the cutting process occurs underneath the surface (green arrow) as in Figure B:
in Figures C & D: the radiofrequency probe (red arrow) in the inferior turbinate (blue arrow)- (not to worry, it is not as painful as it looks) -the scarring occurs under the surface which is spared;
Figure E: CO2 laser probe yellow arrow) inducing changes over the nasal mucosa (white arrow)
© Vincent Tan ENT
1.
Sapçi T, Sahin B, Karavus A, Akbulut UG. Comparison of the effects of radiofrequency
tissue ablation, CO2 laser ablation, and partial turbinectomy applications on nasal
mucociliary functions. Laryngoscope. 2003 Mar;113(3):514-9.
2.
Hol MKS, Huizing EH. Treatment of inferior turbinate pathology: a review and critical
evaluation of the different techniques. Rhinology 2000;38:157-166.
3.
Wexler DB, Berger G, Derowe A, Ophir D. Long-term histologic effects of inferior
turbinate laser surgery. Otolaryngol Head Neck Surg. 2001 Apr;124(4):459-63.
4.
Chen YL, Tan CT, Huang HM. Long-term efficacy of microdebrider-assisted inferior
turbinoplasty with lateralization for hypertrophic inferior turbinates in patients with
perennial allergic rhinitis. Laryngoscope. 2008 Jul;118(7):1270-4.
5.
Liu CM, Tan CD, Lee FP, Lin KN, Huang HM. Microdebrider-assisted versus
radiofrequency-assisted inferior turbinoplasty. Laryngoscope. 2009 Feb;119(2):414-8.
6.
Chen YL, Liu CM, Huang HM. Comparison of microdebrider-assisted inferior
turbinoplasty and submucosal resection for children with hypertrophic inferior
turbinates. Int J Pediatr Otorhinolaryngol. 2007 Jun;71(6):921-7. Epub 2007 Apr 5.
7.
Naveen D. Bhandarkar and Timothy L. Smith. Outcomes of surgery for inferior
turbinate hypertrophy. Current Opinion in Otolaryngology & Head and Neck Surgery
2010, 18:49-53
华文版
.
Examples:
RADIOFREQUENCY VOLUME REDUCTION
MICRODEBRIDER TURBINOPLASTY
RIGHT INFERIOR TURBINATE (RIT)
LEFT INFERIOR TURBINATE (LIT)
RIGHT INFERIOR TURBINATE (RIT)
BEFORE
SURGERY
8 DAYS
AFTER
SURGERY
15 DAYS
AFTER
SURGERY
REMARKS:
S
S
S
S
S
S
S
S
RIT
RIT
RIT
RIT
RIT
LIT
LIT
LIT
S = nasal septum
•
Notice the intact pinkish nasal mucosa lining preserved before and after the surgery
•
Volume reduction of inferior turbinate is appreciated early in the postoperative period, resulting in improvement of nasal airway
•
Surgery does not preclude the use of medication in the postoperative period in some patients, especialli to treat other symptoms.
•
Results, however, may vary in different patients (as healing properties differ among individuals) and therefore preoperative
counselling and discussion is important.
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
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